In addition to clinical aspects of primary care additional dimensions entered consultations which extended responsibilities of doctors and were predominately mediated through IT. These affected how consultations were conducted and decisions were negotiated, doctors perceived an expectation that they must incorporate them into daily practice. These required doctors to simultaneously or serially deliberate on the impact of their actions or recommendations on a number of different levels, or frames, as represented by Dodier in his sociological analysis of medical judgment (Dodier, 1994).
Building on Goffman’s frame analysis concepts, Dodier identified three principle frames; a
clinical frame (symptoms, examination and investigative findings), a solicitude frame
(embracing an understanding of a patient’s situation, an intimate negotiation of what can or must be done for this person and taking into account how the outcome can be justified to outside bodies) and a psychological frame (of seeing behind the surface).
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In research amongst occupational physicians, Dodier observed no difficulty in their shifting from one frame to another as part of routine interactions, though each frame differed from the others in the relationship established by the doctor between the subjective (felt/reported) symptoms and objective (clinically demonstrable) accompanying signs. It remained the duty of each assessing doctor to make a judgement on the balance of evidence presented and taking into account the idiosyncratic elements in the reactions, motivations and consequences for the individual patient. He added a fourth framing concept, an autonomy frame to represent sharing the therapeutic decision-making process with the patient or acquiescence with patient preferences; an idea somewhat removed from the authoritative physician figure of Foucauldian thinking (Foucault, 1963, Dodier and Barbot, 2008). For occupational physicians, as for NHS GPs, the necessity of working in multiple frames added to the complexity of the task expected on each occasion.
Prominent new frames included:
The patient’s presenting problem/s, as subjectively experienced symptoms etc., which may be presented with greater complexity as patients conducted internet searches and used other sources to personally check out their concerns
Lifestyle issues to be addressed (smoking, alcohol, dietary intake, exercise, mental health) and data recorded for QOF and other targets.
Examination findings and further investigations; might require cross-checking against NICE guidelines, disease-specific protocols or local care pathways
Treatment needs; prescribing guidance, relative cost of suitable medication, individual tailoring of treatment.
Prescribing incentives and budgets which were externally evaluated or compared
Referral procedures; available (unrestricted) referral routes, patient choice of services, locally determined pre-referral criteria (e.g. blood tests, x-rays etc.); referral management processes have been developed to monitor and increase GP accountability for referral decisions.
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Substantial proportions of funding linked to compliance means that doctors cannot easily afford to ignore this aspect of medical practice, yet if each frame were aligned with their espoused aspirations, then these shared objectives ought also to be evident in their concepts of ‘good practice’.
What measures quality in medical practice?
Bearing in mind doctors’ concepts of being ‘a good doctor’ and limitations on how many tasks from different frames could simultaneously be accommodated, requirements of performance measurement came as an un-matched additional burden in the workplace, altering the course of consultations (Chew-Graham et al., 2013). This could therefore be viewed as impacting negatively on work patterns by demanding time and attention from the doctor but also by diluting or conflicting with his/her sense of providing adequate holistic care for patients.
At its introduction, attention was drawn to a scientific evidence basis for criteria chosen for clinical measurement under QOF with documentation collating evidence of the clinical impact of inaugural targets. On the strength of this evidence the QOF could be viewed as reinforcing best medical practice with expected improvement in health outcomes for patients - though monitoring quantitative measures produced a partial picture and might not correlate with what doctors or patients valued most (N.H.S. Confederation and British Medical Association, 2003b, Lipman, 2006).
As a single-handed practitioner Alice viewed her QOF scores (and high ratings on prescribing indicators) as evidence of providing a quality service. Her practice scores became part of the body of information available to those monitoring her practice when unavoidable circumstances left her unable to confidently deliver continuing care. However, she recognised that this was in large part due to the efforts of her team since she was periodically absent from the practice;
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‘QOF is a team target … delivered by a team of people and I can’t take the credit for achieving that completely on my own … I have got a good team who do it… with me’ Alice
As new standards were added and some of the supposedly strong evidence called into question by further research, this caused uncertainty about the effectiveness of recommended clinical management; some doctors expressed their own doubts about the clinical usefulness of the evolving QOF (Tracy et al., 2003, Willis, 2009). Reticence about the purpose of achieving the full range of QOF standards led to a degree of ambivalence or frank disagreement as in these examples:
‘I suppose we ought to be doing things where there is an evidence base that it’s actually doing some good. And some - you know you are not going to find out if someone has got hypertension and reduce the risk of stroke unless you measure it, so to encourage people to start measuring blood pressures is a good thing’ Richard ‘they keep squeezing in stuff and they keep making it harder, and then it starts to feel that way [ immoral ] … so its glory days are well and truly diminishing in my view’ George
With a constantly-changing evidence base and diverse ideas about credibility attached to the quality of emerging evidence by established clinical experts – including suspicion of potential conflicts of interest by sponsoring pharmaceutical companies, keeping clinicians in agreement on ‘best practice’ is a shifting goal for which NICE attempts to provide guidance (Goldacre, 2009).
It matters more because of linked payments
Frustration resulted from ongoing efforts to keep recorded data in a form which was recognised for assessment purposes; Jennie reported examining records to detect omissions;
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‘…medication review isn’t ticked…although they have been reviewed, they are on the right amount of medication, they have had their bloods done…’ Jennie
In other words, full medical care had been delivered but the computer record for specific codes did not confirm it and this record would be counted as failing to achieve the standards required – a case of doing everything apart from what triggered payment.
In Jennie’s practice, shortly after the introduction of the QOF and while continuing to work towards improving target achievement, they suddenly found themselves without a Practice Manager to lead and co-ordinate the team’s efforts. As Senior Partner, she felt responsible for improving income by investing extra time and taking on tasks beyond her expertise to extensively audit and review records to improve figures.
She admitted that she set about this ‘without thinking about it properly and planning it’, attributing her attitude to having trained in a culture of ‘just getting on’ with what needed to be done. In consequence she heavily overloaded herself and faced a serious complaint from a member of staff who had likewise felt over-stretched by her actions during this time. Jennie’s reflections indicated that she was re-thinking whether her overwork in an unfamiliar area had been the best course of action;
‘maybe I shouldn’t have taken it all on … because there are prices to pay for everything isn’t there really and that was the price … [it] was a completely new field to me and I just didn’t, wasn’t aware of what the rules of the game there are, or anything really.’ Jennie
145 What are you doing the job for?
Certain times
the balance of expenses and income was becoming more and more tricky you think
what are you doing this job for
when the expenses are going to be so huge when you think of the number of hours for the QOF
and just generally
because of the nature of the job
the way that the hours are just chewed up the rewards are getting less
and less
You have got to think again Is the stress more than it’s worth at times
really?
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The issue of having all clinicians fully engaged with properly entering data came into sharper focus with QOF requirements when one of Jennie’s colleagues remained reluctant to do his share – a problem which had not been resolved. Her misgivings mounted when she led the practice to an expensive purpose-built surgery and questioned her reasons for carrying on despite financial concerns;
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What are you doing the job for?
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New facilities must be paid for but increasing profitability through working even harder was an unattractive option – her metaphor of ‘chewed up’ time hints at recognition of regret that precious, finite time was too quickly slipping from her control and for scant rewards.
Takes the joy out of the exploration of the patient’s illness/problems
Because of his preferred working style, Richard was frustrated by the demands conveyed through the IT system;
‘I always feel the pressure to do all these things and tick the boxes and get everything done, because…I like to get it all done so I can say “sorted”.’ Richard
Previously he loved to spend time with patients investigating the cause of their problems and helping them to resolve them. Now his appointments ran over time increasing stress levels while his enjoyment of investigating unusual cases or exploring knowledge must wait until later; after his list of things to do had stopped growing he could relax, delve into cases to
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better understand them and increase his knowledge, communicate with colleagues and be comfortable;
‘The time I find I am most relaxed is not doing surgery [consultations] … it’s after everybody has gone home and I can sit and think and … I can do a dictation, type a letter up or have a look at somebody’s blood results and look on Google about what their illness is, and I think oh that’s interesting.’ Richard
Richard’s thoughts about how long he may continue in work were linked to this increasing pressure and diminished satisfaction. Although he had anticipated continuing to work until aged 65, he had started to consider earlier retirement and reflected that many older doctors had already done this.
Enjoyment of work had also reduced for Mark leading him to become disenchanted; ‘I think you know it’s like you have got to enjoy your work, got to look forward to going into work.’ Mark
‘Occasionally it does seem like it’s an impossible job …most of us feel like that … you are…doing your best and you haven’t got the support, or you get criticised.’ Mark Mark sensed a mismatch between what he believed delivered best care to patients and what was expected from him and troubled by managing uncertainty in isolation;
Everything falls on you here…you are left… but it’s a big responsibility.’ Mark
‘We don’t seem to be in control of you know the kind of what good is and how we could make it good, better and you know lead to better standards you know.’ Mark ‘I [have] got another 10 / 15 years of that, everyone seems to be developing tighter and tighter criteria reasons for declining [referrals].’ Mark
Despite his best efforts, a combination of trying to achieve high standards with limited resources, inability to define good standards according to criteria, he believed worthy of achieving, yet knowing that he frequently bore final responsibility and would readily be
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criticised; all these drained enjoyment and enthusiasm as he considered continuing with this until he could reasonably retire.
Compliance with recommendations to avoid being considered a bad doctor
Aligning contemporary medical practice with the recommendations of Evidence Based Medicine (EBM) re-defines good medical practice in terms which include appropriate use of diagnostic tests, efficient use of specialist departments and restrictions applied to prescribed medication. Emphasis can focus on empirical evidence as a superior form of knowledge though others have argued for greater inclusion of other forms of knowing such as experiential evidence and patient and professional values (Tonelli, 2001). As EBM advice is regularly revised in the light of new publications, each reiteration cannot itself be held to have been unalterably dependable though it may have been the best advice then available.
Articles in the lay and medical press have questioned the validity of presented evidence with allegations of bias in favour of pharmaceutical companies who part-sponsored new research and such questioning can affect clinicians’ opinions (Goldacre, 2009, Schott et al., 2010). When doctors lost faith in the value of what they had to do, sometimes they only did it because of incentives or to maintain a good reputation. For example, Richard said;
‘There are a number of things which I think, well, I know I am ticking the box, because if we don’t tick the box we don’t get the points.’ Richard
‘…you could fall behind the evidence base and say I know that I want your cholesterol to be below 5 but actually that’s quite good for you.’ George
‘there are a lot of, dichotomies aren’t there about things; like when do you stop prescribing statin for instance, and I think it hasn’t been addressed and I have got patients … still on statins in their 80s when there is no real evidence it will make any difference.’ Stewart
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Stewart’s practice employed ‘an army’ of staff to ensure that all available points were achieved but he resented the implication that because he could not agree with all the recommended actions of the QOF he would be branded as a bad doctor. Like others, his preferences were not always rewarded under the QOF since they lay in developing relationships with patients, empowering them to make healthy lifestyle choices and developing services which would be more effective in helping and supporting them; hence his attitude supported tactical responses like playing a PCT-led game for mutual benefit.