Feature

Never mind the quality

Are contracts a useful approach to improving the quality of care? Juan Baeza and Michael Calnan have their doubts

Standards and quality of care have been major concerns in general practice, particularly over the last decade.¹ A range of strategies have been put forward to improve quality, including peer assessment, medical audit, clinical guidelines, continuing education and payment systems.

The contracting process within the internal market introduced another mechanism for specifying quality standards, particularly at the interface between primary and secondary care. Purchasers were given the role of identifying the healthcare needs of their catchment population and the contract with the provider would be a means of ensuring that these needs were met. Through contracts GP purchasers can influence the quality of care provided by their colleagues in the hospital sector.

But does this work in practice? A case study carried out in a large fundholding consortium explored the contracting process for the services provided in an outpatient department, specifically focusing on the way quality standards were developed and how they were implemented by the multifund. Twenty-one interviews were carried out during the winter of 1996 with the major contracting stakeholders: GPs, hospital consultants, fundholding managers, hospital managers and health authority managers.

It became clear from the interviews with both purchasers and providers that there was ambivalence about the relevance of the contracting process, which was seen as an unnecessary and rather meaningless ‘paper chase’.

Purchasers and providers agreed that quality was of major importance, as one GP said: ‘The whole basis of wanting to improve primary and secondary healthcare is all tied up with the quality standards and I think this is the very centre of fundholding.’

But there seemed to be a gap between perceived ideal and actual practice: in reality contracting priorities lay with the financial implications of the contracts and monitoring activity levels. Lack of time was the main reason given for this. One fundholding manager said: ‘I think really pressure of time to do all the other things we’re trying to do... realistically it would be very difficult to do it [monitoring of the quality standards] with the resources we’ve got at the moment.’

But even if there were no time constraints there are doubts whether fundholding managers and GPs have access to the necessary skills and tools for carrying out effective quality monitoring.

GPs’ ambivalence about fundholding has been well-documented and one of the attractions of large fundholding consortia for many GPs is that they can hand over financial and managerial aspects of contracting to professional managers, areas in which they have neither interest nor skills. But the consequence has been a limited awareness and involvement by most GPs in constructing and implementing quality standards. As one of the GPs said: ‘Well, I won’t say they’re not interested, they certainly don’t know. My partners haven’t a clue about what the quality standards in the contracts are. Most GPs are not terribly interested in the mechanics, they just want to get their patients in and get a good opinion.’

In the fundholding consortium we studied, the process of deriving the quality standards had been quite rudimentary. Many of the standards were taken ‘off the shelf’, from the Patient’s Charter or other fundholders, with little discussion about their value locally.

This lack of participation was not just a characteristic of the purchasers. Providers also had little involvement in developing the standards. This lack of negotiation and flexibility was a source of dissatisfaction for hospital contract managers, because it meant that the standards agreed with the hospital were never complied with entirely. Perhaps more significant was the fact that this did not really matter; evidence from our study suggests that hospital consultants were unaware of the quality standards: ‘I mean it’s very difficult to comment on [the multifund’s] quality standards when I haven’t seen them but you mention one of its contents, and we’ve talked about the discharge summary issue before and certainly having that in the contract, as far as I am concerned, doesn’t seem to have altered what is actually delivered.’

The consultants’ attitude might reflect the lack of penalties for non-compliance or rewards for compliance. Hospital consultants tended to suggest that while there was nothing wrong with the quality standards themselves, no resources were provided to support their implementation. The consultants’ ambivalence towards the standards may have reflected the state of the local healthcare market and in another area, with a wider choice of providers, there might be more incentive for providers to comply with standards.²

Evidence on standard-setting suggests that effective implementation in terms of changing clinical behaviour depends, at least in part, on the extent to which those who are expected to comply with the standards are involved in developing them.³ As well as greater participation there is also a need for greater flexibility on the part of purchasers, so that the targets are seen by both purchasers and providers as realistic and attainable within existing constraints of time and money.

Improving standards through contracts is one of the latest attempts to improve quality in healthcare. The evidence from this study suggests that, as with other strategies for quality enhancement, a more participatory approach is required if the approach is to be effective. But whether a market orientated philosophy is conducive to this remains an open question.⁴