Paying GPs for Dementia Diagnoses
A GP in Guildford has recently revealed that the NHS is to pay GPs £55 each time they diagnose dementia in a patient. Writing on the medical website Pulse, Dr Martin Brunet, called the incentive scheme a “bribe,” put in place so that the government can “hit its target to raise diagnosis rates.”
The ‘Dementia Identification Scheme’ requires GPs to count how many patients with a dementia diagnosis there were on their register at the end of September, and to compare this with the number at the end of March 2015. They will then receive £55 for every extra patient. The full service specifications can be found here.
Dr Brunet writes:
No-one is against correctly diagnosing dementia, but NHS England have either not considered the ethics of this new policy, or are so blinded by their goal that they don’t deem ethics to be important – either a lack of moral insight, or a failure of moral leadership.
We are used to being paid for things of course, like asthma reviews and statin prescribing, and we are well aware of the problems this causes – but at least patients can opt out if they don’t like it.
They can refuse to attend a review, decline our offer of a statin or politely take the pill packet and store it unopened in the kitchen cupboard. They cannot opt out of a diagnosis.
The point of making a diagnosis is something the doctor does alone. The patient can contribute, of course, they provide evidence and we certainly want to know what they think, but the moment of judgement is for the doctor and is enormously difficult for the patient to challenge. What we code in the notes really is up to us, which is why there must be absolute trust that the doctor is acting only and solely in the best interests of the patient.
To contaminate this process with a financial payment seriously undermines the doctor-patient relationship in a new and pernicious way.
If we sign up to this DES are we going to explain to our patients the profit we will make from diagnosing them? We would expect an insurance salesman to be transparent about the commission he would make if he sold us a policy – why would doctors be above the need for such transparency?
How will our patients feel if they knew? If you can look them in the eye and explain why you should be paid according to the diagnostic label you apply then go ahead and sign up – I for one could not do that.
And how will you feel about undiagnosing your patients if they’ve been misdiagnosed?
I’ve undiagnosed patients twice in the last year, and had to fight hard for a second opinion in one case when a trainee diagnosed dementia on the basis of an MRI scan alone without really talking to the patient.
Were I signed up it would cost me £55 a time to get these patients correctly diagnosed; might I hesitate if I knew that?
I am not naïve about the financial pressures we are under, but nor am I going to believe that we have no choice but to accept this. To find 10 new cases in the next six months would be some going – and it would only raise £550 in funding from the DES.
There appear to be two sorts of concerns highlighted here. The latter concern that Dr Brunet alludes to is largely an empirical matter; the idea that introducing cash incentives would cloud and influence GPs’ judgements. The thought seems to be that the prospect of receiving financial reward for an extra dementia diagnosis could cause GPs to misdiagnose outright, or to resist changing their mind or seeking a second opinion if they were unsure about a patient. This type of concern is particularly heightened in the case of diagnosing dementia where there is no accurate screening test, as opposed to say, the incentives given to GPs in diagnosing diabetes, where there are such tests. It seems that the effectiveness of this sort of argument against the practice would hinge on the following empirical observations:
(a) whether there was an actual increase in dementia diagnoses, and whether this could be attributed to the new scheme
(b) whether these diagnoses turned out to be wrong and/or were subsequently retracted
It appears that (a) would be tricky to observe in that unless there really was a sudden and pronounced increase in diagnoses, it would be difficult to say whether this was a direct result of the incentives scheme. The second condition, (b) could be difficult to pin down due to the length of time required to make such a judgement, and perhaps due to the difficulty in making such a counter-judgement in the first instance, once a diagnosis has already been made.
Perhaps then, the moral case Dr Brunet makes is more promising. I believe the most powerful argument he invokes is that this scheme runs contrary to the doctor-patient relationship in a very fundamental sense.
There appear to be 2 key ways in which Brunet believes doctor-patient relations are threatened by this scheme:
1) it is is a violation of patient autonomy, as patients cannot ‘opt out’ of a diagnosis, like they can do with other incentivised schemes that they would prefer not to be a part of
2) the policy requires transparency between doctors and patients – either this goes unfulfilled and threatens the doctor-patient relationship due to the presence of deceit, or the transparency condition is fulfilled and trust is lost as patients become aware that their interests are now no longer the ‘sole interests’
These concerns fundamentally alter the nature of the relationship, which, as it currently stands, is a cornerstone of medical ethics and central to the practice of delivering high quality health care. Even if the empirical arguments don’t turn out to stand up, the moral argument holds that something intrinsic to the doctor-patient relationship would be lost, and that this would be bad because of how we currently value the relationship, and its constituent features of autonomy and trust.
Latently operating in this worry about the doctor-patient relationship is a concern about the application of market norms to the realm of primary care. It would be useful to bring these concerns to the surface. In an important paper on commodification, Elizabeth Anderson argues that:
To say that something is properly regarded as a commodity is to claim that the norms of the market are appropriate for regulating its production, exchange, and enjoyment. To the extent that moral principles or ethical ideals preclude the application of market norms to a good, we may say that the good is not a (proper) commodity.
For Anderson, one reason to object to the application of market norms to the production or distribution of a good is that “to produce or distribute the good in accordance with the norm is to fail to value it in an appropriate way.” And there are many objects of a higher mode of valuation than market use, which are therefore not properly regarded as mere commodities. It seems plausible that the doctor-patient diagnosis relationship is one of these ‘objects’. For this relationship to flourish and be valued properly, its enjoyment must be removed from market norms and embedded in a different set of social relationships. How are we to appropriately value the doctor-patient relationship? Although there are steps missing to this argument as it stands, the underlying idea is that there is something in the nature of the relationship, such that its commodification in the sense exhibited by the cash for diagnoses scheme, can be seen to disvalue it, and threaten both our appreciation of it, as well as its function. This sense of the ‘proper valuation’ of the doctor-patient relationship, therefore, is what I think critics such as Brunet are appealing to in their condemnation of the scheme.
Anderson, Elizabeth, “Is Women’s Labor a Commodity?” Philosophy and Public Affairs (1990), 19:1 pp.71-92