Thursday, 10 December 2009

A poor target

In my view, one of the faults of our Government is that they prefer appearance to substance. They give us a lot of targets to achieve but, as Einstein said, not everything that can be counted counts, and vice versa. We put quite a lot of effort into achieving these targets since there are financial rewards attached, but not everything seems worthwhile and there is the risk of ignoring other areas which count but can't be counted.

A case in point is the Cancer Care review. We receive a financial reward for demonstrating that we have carried out a review of all our cancer patients within six months of the diagnosis being made. This is an easy thing to measure: you search for patients who have a cancer diagnostic code on their computer record, and see how many of them have the "cancer care review" code within six months of that date. But for most patients this is not the time for the GP to be doing a review. Immediately after diagnosis the patient's care will be taken over by the hospital where they may have an operation, chemotherapy or radiotherapy. After this initial treatment phase they will, with luck, go into remission and have a decent period of time with no disease. The time the GP's input is required is if and when the cancer recurs and you have to start planning for terminal care. But this could be at any time, and there is no easy way of measuring it by analysing computer codes.

Today I saw a lady in her 70s. Twelve months ago she had consulted me about vague abdominal discomfort and some increase in bowel frequency for a few weeks. That was all, she had no other symptoms. I recognised that these symptoms sounded suspicious and referred her urgently. She had her rectal cancer removed the next month. It had reached the "Duke's B" stage, which means that she has an 80% chance of being cured. But we did not see her again in surgery within six months, there was no need. So we lost a little income because we had not done the Cancer Care Review that the Government had ordained.

On the other hand, I may have saved her life by recognising the significance of her symptoms at a time when her cancer was still curable. I certainly think that I did her more good by referring her early than by doing a futile review after she was discharged from hospital. Not everything that counts can be counted.


Pam said...

Indeed. We FE teachers have to deal with similar silly targets (though they don't affect our pay). Never mind having time to teach our students; as long as they pass a module in 19 weeks, that's fine. About five of those 19 are taken up by assessments instead of teaching or learning, but hey. Figures, that's the thing.

I do enjoy your blogs.

The Shrink said...

But how sustainable is it for many practices to keep doing what's right, not what's financially attractive?

Inappropriate outcome measures and the vogue for (swiftly and poorly) implementation of "quality metrics" pertrubs me.

Much badness.

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Nikita said...

Merry Christmas and a Happy New Year.

Mags. xxx

Unknown said...

Hi Doc...I'm a 3rd year med student right now so I realize I definitely do not have experience like you do but I think the "system" is expecting that docs do not stop making diagnoses in favor of doing 6 month reviews but both :) I think I understand your point though...a doc might be tempted to simply target patients who have recently been diagnosed and not pay as much attention to other stuff trying to meet financial incentives...I live in the US but I'm definitely interested with the prospect of moving abroad...perhaps reading your blog (first time reader) will help me understand more about practicing in England...keep saving lives doc!

Dr Andrew Brown said...

Thanks everyone for your comments. I think that audit and targets are fine up to a point, and can help improve care. But if there is too much emphasis on them then priorities become distorted.