Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract
Address for correspondence: Kath Checkland, National Primary Care Research and Development Centre, 5th Floor, Williamson Building, University of Manchester, Oxford Road, Manchester, M13 9PL e-mail: email@example.com
In 2004 a new contract was introduced for General Practitioners in the UK, which introduced a significant element of ‘pay-for-performance’, including both clinical and organisational targets. The introduction of this contract has caused interest across the world, particularly amongst those responsible for commissioning primary care services. It can be argued that the clinical targets in the contract (known as the Quality and Outcomes Framework, QOF) represent a move towards a more biomedical model of health and illness, which is contrary to the ideal of providing holistic (or biopsychosocial) care that has been traditionally espoused by GPs. This paper reports results from two linked studies (in England and Scotland) investigating the early stages of the new contract. We describe the way in which four practices with different organisational approaches and espoused identities have all changed their practice structures, consultations and clinical care in response to QOF in ways which will result in patients receiving a more biomedical type of care. In spite of these observed changes, respondents continued to maintain discursive claims to holism. We discuss how this disconnection between rhetoric and reality can be maintained, and consider its implications for the future development of GPs’ claims to a professional identity.
In 2004, a new contract for general medical practice in the National Health Service (NHS) was introduced. This General Medical Services (GMS) contract included, amongst other provisions, 146 evidence-based indicators of quality (collectively termed the Quality and Outcomes Framework or QOF), and paid practices for meeting targets derived from these indicators. Although the principle of partly remunerating general practitioners (GPs) for achieving quantifiable targets is not new, QOF takes it far beyond previous incarnations in respect of both the number of targets and the proportion of practice income that is dependent on their achievement. It has been described by an American commentator as a ‘bold proposal’ that ‘vaults over anything being attempted in the US’ (Shekelle 2003), and its outcome is awaited with interest across the world (Mangin and Toop 2007). Criticisms of the contract have largely focused on the apparent ease with which practices have obtained higher-than-forecast QOF scores and earnings (Timmins 2005), though it has also been seen as ‘an unprecedented system of central control and external surveillance’ (Jeffries 2003: 888). In contrast, we are concerned here with the effect of the new contract on GPs’ practices and the manner in which GPs present themselves in terms of models of medicine. Since the middle of the last century, this self-presentation has been dependent on claims to practise in a manner that has been variously termed ‘holistic’, ‘patient-centred’ and ‘biopsychosocial’, in contrast to the ‘biomedical model’ said to underpin hospital specialist medicine. Although it cannot be assumed that these terms unproblematically describe the practice of either branch of medicine, the medical activities incentivised by the new GMS contract imply a model of medicine that significantly violates these traditional GP claims. In this paper we explore empirically the manner in which GPs in two English and two Scottish general practices have responded clinically to the requirements of obtaining desired QOF scores under the new contract and how they relate these responses to claims about holistic practice. What follows is divided into six sections. A discussion of the historical development of the concepts of biomedicine and holistic practice in the UK is followed by a brief description of the new GMS contract. We then describe our methods and the study setting, and two further sections set out our results. A final discussion section considers the implications of our findings.
Biomedicine, holism and general medical practice
In the history and sociology of medicine, the so-called ‘medical model’ (from the 1950s and hereafter in this paper ‘biomedical model’) of illness is employed to characterise the historical and ideological underpinning of contemporary beliefs about the nature of, and remedies for, illness. Historically, the model describes a break with previously prevailing models of medicine that saw ill-health very much as an imbalance within individuals and a deviation from the individual's natural state (Cantor 2000: 348). Jewson (1976: 232) describes this as a shift from ‘bedside medicine’ to ‘hospital medicine’, and identifies ‘a shift away from a person-orientated to an object-orientated cosmology’. The break is said to have occurred sometime in the late 19th Century, inspired in part by the scientific discovery of specific agents for diseases such as tuberculosis and cholera, and reinforced by subsequent medical advances such as diphtheria antitoxin, asepsis and penicillin (Cantor 2000: 350–1). Jewson (1976: 235) argues that, as a result of these discoveries ‘interest in the unique qualities of the whole person evaporated, to be replaced by studies of specific organ lesions and malfunctions.’ The model therefore embodies both a form of reductivism, by which disease is seen to reside in the body of the individual, best treated by interventions specific to the disease process (Lawrence 1994: 75) and mind/body dualism in which the body can be regarded as a quasi-machine that is the passive target of therapeutic interventions, without the need for much attention to social or psychological factors. Diseases became dissociated from the bodies that hosted them, and therapeutics became directed at the disease rather than the person; individual illness thus only had meaning for practice to the extent that it could be ‘mapped onto pathological processes that were common to populations of patients’ (Cantor 2000: 348–9).
There were critiques of the biomedical model from early in the 20th Century from a number of perspectives, including concerns about reductivism and clinicians’ suspicion of laboratory scientists who did not encounter patients. These led to attempts ‘to revive older notions of the body and disease and, from 1926, to label them holistic’ and to the invention of ‘social medicine’ (May and Mead 1999: 80; Cantor 2000: 353–4). Moreover, by its very nature, the biomedical model could have little impact on medical practice outside the hospital, and Armstrong (2002: 61) notes the reappearance in the 1930s of the patient-as-person as an ‘idiosyncratic interlocutor between disease and doctor’. Nevertheless, and despite providing neither a description of all medical practice nor an unchallenged ideology, the model provided an overarching discourse for medicine generally, evidenced by the disappearance of the ‘patient-as-person’ from medical textbooks (May and Mead 1999: 79).
These critiques of the biomedical model thus appear not to have undermined the high political status of specialised hospital medicine in relation to general practice. According to Armstrong (1979), the dominance of the biomedical model was both a consequence and a determinant of the domination of hospital medicine over its community general practice counterpart. In addition to what Armstrong (1979: 1) calls the ‘subjugation’ of the patient, there was an equivalent decline in the status of GPs, who not only had no area of specialisation to call their own, but who had also become dependent on their hospital colleagues for ‘admission rights’ to hospitals. Furthermore, by their domination of research, hospital doctors became the producers of knowledge, whilst GPs were relegated to the role of consumers of that knowledge. Hospital specialists were often scathing about the intellectual calibre of GPs and of any aspirations to increase their status (Drury 1998: 211, 214; Rivett 1998: 163). Thus, in the early years of the NHS, GPs often sought to keep in touch with medical developments and to counter their sense of dealing with clinical trivia by performing part-time hospital work as sub-consultant ‘clinical assistants’ (Armstrong, 1979: 3).
It was from this situation that the plan to create a College (later Royal College) of General Practitioners (RCGP) emerged, and this institution was founded in 1952 (Drury 1998: 213). The new College's role was from the beginning explicitly academic, a situation that necessitated the development of an approach to professional knowledge that was something other than an attenuated version of hospital specialisms. By the early 1960s, claims about what a GP was ‘for’ had come to focus on such matters as personal knowledge of patients and concern for the whole person (Batten 1962, Smith 1962). Balint's (1957) seminal work on the potential value of doctor-patient interactions in primary care lent credence to these new areas of concern, and by the early 1970s a clear definition of general practice as a discipline that reclaimed Jewson's (1976) notion of ‘the sick man’ was being developed. College publications such as The Future General Practitioner (1972) defined general practice as being concerned with ‘the patient's total experience of illness’, and is credited by Howie et al. (2004) with coining the phrase ‘patient-centred practice’. By the 1970s general practitioners were beginning to use claims to ‘holism’ to counter the dominance of the hospital-based biomedical model and in the process to boost their claims to professionalism. It is worth noting that they were doing so in a context in which the biomedical model was under attack from other quarters, including social scientists, feminists and others who saw it as political in the sense of diverting attention from the social and economic causes of disease (Cantor 2000: 357–8). Similar changes were occurring in some other medical disciplines. Faced with the paradox that psychiatrists, working within hospitals and therefore in an environment dominated by the doctrine of ‘specific aetiology’, could rarely point to a physical lesion causing the diseases that they were treating, Engel (1977) coined the phrase ‘biopsychosocial medicine’. He argued that the biomedical model alone was inadequate to explain all manifestations of illness, and suggested that in addition to biological lesions physicians should also take into account cultural, social and psychological considerations. GPs enthusiastically adopted this term, and it is to be found in many RCGP publications as well as in the curriculum of the general practice training programme.
Thus, GPs had claimed their own model of medicine, variously referred to as ‘holistic’, biopsychosocial’ or ‘patient-centred’. In subsequent decades this has remained prominent in GP rhetoric, constituting a claim to an area of professional knowledge of their own, distinct from both the dominance of their hospital colleagues and the claims of population-based approaches. In 1996 a RCGP Working Party contrasted ‘generalists’ and ‘specialists’ in the following terms:
Specialists are defined by the range of problems for which their specific competence is required. Generalists are defined by the list of people that they serve and their breadth of clinical competencies. Their accumulated knowledge of these individuals, their families and community gives them the expertise required to provided personalised care (RCGP 1996: 4).
This report went on to assert that: ‘the personal doctor-patient relationship is culturally and professionally deep-seated’, and that: ‘It is the responsibility of the Royal College of General Practitioners and those running higher professional training programmes to ensure that person-centred general medical practice continues to be taught, researched and valued’ (1996: 7).
Hasegawa et al. (2005) report the results of a survey of all GPs in Scotland, in which 87 per cent agreed with the statement that ‘a holistic approach’ was important in providing good-quality primary care, whilst GPs studied by Sanders and Harrison (2008) used the notion of holism to distinguish their role from that of cardiologists in the treatment of heart failure. This focus on personal and holistic care is not unique to the UK; WONCA, the association of national associations of general (or family) practice includes in its mission providing ‘personal, comprehensive and continuing care for the individual in the context of the family and the community’ (http://www.globalfamilydoctor.com/aboutWonca/aboutwonca.asp?refurl=aw, accessed August 2007).
May and Mead (1999: 83ff) have demonstrated the wide range of often vague understandings that have attracted the label ‘patient-centredness’. Early writings from the Royal College of General Practitioners (1972) referred explicitly to considering the whole person and their context. However, under the influence of Balint's (1957) work, general practice teaching and much of its research concentrated upon the conduct of the consultation; over time, considering the whole person came to be equated with having a ‘patient-centred’ consultation style that took into account the patients’ concerns (Larivaara et al. 2001). Howie et al. (2004) make this link explicit, arguing that patient-centredness in the consultation is the means by which the value of holism (which they equate with biopsychosocial medicine) is delivered in practice. Other strands of general practice literature have emphasised the important role of GPs in managing complexity in the sense employed in complexity theory (Griffiths and Byrne, 1998, Innes et al. 2005). However, a slippage of language has allowed the equation of ‘managing complexity’ with holism:
Complexity science suggests. . . . that illness (and health) results from complex, dynamic, and unique interactions between different components of the overall system. Effective clinical decision making requires a holistic approach that accepts unpredictability and builds on subtle emergent forces within the overall system (Wilson et al. 2001: 688).
Similarly, Freeman (2005) equates holism with biopsychosocial medicine to which are added the additional dimensions of patients’ cultural and existential concerns, arguing that concern with complexity is the essential defining feature of holistic general practice. Thus, ‘holistic’ general practice has a variety of meanings, and some authors have argued that it remains a rhetorical rather than a real commitment (Dowrick et al. 1996, Gavin 2004). In spite of these challenges, discourses of holism and patient-centredness nevertheless remain central to GPs’ professional self-presentation (Hasegawa et al. 2005).
In the last decade primary care, like other branches of clinical medicine, has been very much affected by ‘evidence-based medicine’ (Eve and Hodgkin 1997), defined by its academic advocates as ‘the integration of best research evidence with clinical expertise and patient values’ (Sackett et al. 2000: 1). Although this approach privileges randomised controlled trials and meta-analyses of such trials as the ‘best research evidence’, it also emphasises the importance of interpreting and critically appraising such evidence in the context of individual patients’ unique health states and personal preferences (Sackett et al. 1996). Expressed in these terms, evidence-based medicine seems entirely compatible with the primary care discourse of holism, patient-centredness and the biopsychosocial model of medicine. However, as Harrison (2002) has argued, the ‘critical appraisal’ model espoused by these authors has, in the NHS, been overtaken by ‘scientific-bureaucratic medicine’; that is the translation of research findings into ‘clinical guidelines’ for more-or-less routine application to whole classes of patients. This population-based approach to treatment corresponds to the abstraction of disease implicit in the biomedical model; as Byrne (2004) has noted, there is no necessary relationship between evidence of treatment effectiveness in a population and effectiveness in individuals within that population. Some GPs have consequently been sceptical about evidence-based medicine; Marinker (1996: 10–11) asserted that ‘truly holistic’ general practice had developed from the efforts of the RCGP and expressed concern that evidence-based medicine ‘somehow misses the point of the clinical encounter’ in general practice. Yet the implicit policy commitment to the biomedical model is manifest in numerous attempts to discover organisational interventions to increase the implementation of clinical guidelines by GPs, with somewhat mixed findings (Effective Health Care Bulletin 1999, Harrison and Dowswell 2002, Harrison et al. 2003, Russell and Grimshaw 1992).
The documentation issued with the new GMS contract emphasises the evidence base underlying QOF and the improvement in patient health expected to follow from its adoption (Department of Health 2003b, 2003a). QOF thus embodies a biomedical approach to practice, expressed in terms of standardised guidelines, implemented by paying practices to conform. Seen in these terms, the new GMS contract raises questions both about how GPs respond in terms of their clinical practice and what they say about it. First, we investigate whether general medical practice has become more biomedical and disease orientated in the wake of QOF. Secondly, we investigate whether GPs continue to make discursive claims to holism/patient centredness, the substantive content of such claims, and how they can plausibly be maintained in the context of post-QOF practice.
The 2004 General Medical Service contract
Although there are several ways in which the UK-wide 2004 General Medical Services (GMS) contract differs from its 1990 predecessor, the QOF is the focus of this study. The QOF radically extends the scope of practice activity incentivised by measurement, and makes up to 20 per cent of practice income dependent on performance. It is important to note that official statements surrounding the introduction of the contract emphasised the voluntary nature of the targets, suggesting that GPs could prioritise those most relevant to their own practice (Department of Health 2003b: 20). Practices are paid for their performance measured against 146 indicators of clinical and organisational quality, with each indicator worth a specified number of ‘points’ of which 1050 are achievable in total. In 2004/5, each point was worth approximately £75, rising to £120 in 2005/6. Approximately half of the points are allocated for meeting non-clinical targets, including administering patient satisfaction questionnaires, undertaking staff appraisal and assessments of the quality of medical records. The remaining points depend on clinical quality measures for 10 diseases, often closely related to existing clinical guidelines and National Service Frameworks. For instance, practices are paid according to the percentage of their patients with heart disease treated with aspirin, gaining no points until over 25 per cent are treated, increasing to seven points at 90 per cent. Clinical indicators are very specific and narrowly medical in focus, specifying quite challenging targets that are unlikely to be met without the adoption of a pharmaceutical approach. For instance, patients with blood pressure in excess of 150/90 are unlikely to reduce it quickly by exercise and diet. Thus, the system, which allows a limited time within which newly diagnosed patients are allowed leeway to work towards the targets, provides a disincentive for practices to encourage patients to adopt lifestyle changes rather than medication. QOF does include so-called ‘holistic’ points, but these define ‘holistic’ in terms of achievement in all disease areas rather than attempting to measure or assess holism in relation to individual patients. Practices are allowed to remove from the denominator of the calculation (‘exception report’) patients who fail to respond to three appointment invitations, decline particular treatment, or are intolerant of treatment. Practices were predicted to achieve 700–750 points in total, but mean achievement for 2004–05 was approximately 950 (Cole 2005: 457). QOF is designed to be regularly reviewed, and the first set of changes was implemented from April 2006, with seven new disease areas added, some indicators dropped or merged, and a reallocation of some points between areas. Some of the new targets introduced proved professionally controversial, but there has been little evidence of any decisions by practices that these, or indeed earlier targets should be ignored.
Methods and setting
We undertook two linked ethnographic studies (in England and Scotland), each comprising two case studies of general practices, focusing upon the effect of the new pattern of incentives to which practices are subject (McDonald et al. 2007). In this paper we report our findings in relation to the model of medicine adopted in response to QOF and the way in which GPs represented this. Following ethical approval in each country, the four practices involved in the study were chosen pragmatically, largely based upon their willingness to participate in a project that had significant implications for them at a very busy time (towards the end of the financial year) and on their willingness to allow researchers to spend time observing all aspects of the practice. Ethnographic methods have not been used extensively in general practice, and for most of our participants this was a new experience. The practices differed in their history, organisation and ethos, from a practice that prided itself on its modernity, to one that embraced a more traditional identity, and from one that had had no significant change in medical personnel for 15 years to one that had had a considerable turnover of staff. Both English practices had high QOF scores but one of the Scottish practices was nearer to the mean. The studies were separately funded, but the two groups of researchers collaborated closely, meeting regularly at the planning and execution stages of the projects, sharing results and discussing emerging findings. The fieldwork took place between November 2005 and May 2006.
‘Medium’ practice has four partners, three of whom work part time, and is in a largely suburban area in England. They employ three nurse practitioners, who see patients with acute illnesses alongside the doctors, and have two healthcare assistants who perform routine tasks such as blood pressure checking. One of the doctors acted as ‘executive partner’, tightly controlling all aspects of the practice's organisation, and taking overall responsibility for meeting QOF targets. ‘Big’ practice is situated in a more deprived area in England, and is larger, with seven partners and two salaried GPs. The nurses in this practice focus their work more upon the management of chronic disease, specialising, for example, in heart disease or asthma. Management here is more devolved and less formalised, with no one doctor taking overall responsibility, although towards the end of the fieldwork period a more formal management structure was instituted in order to address perceived problems of differential commitment amongst the GPs. In order to manage their response to the new GMS contract, some of the doctors and nurses were given individual responsibility for ensuring that particular targets were met. ‘Family’ practice is situated near the centre of a large city in Scotland, and has three full-time GP partners, with three part-time nurses. They are self-consciously traditional in their approach, being proud of their ability to know their patients individually. They have no formal management structure and few meetings. However, one GP takes overall responsibility for meeting QOF targets, and co-ordinates all efforts to ensure that patients meet the targets. Whilst in the first year of QOF these efforts were fairly loosely structured, by the end of the second year the doctor concerned was finding it necessary to develop a more formal system. ‘Modern’ practice, by contrast, is larger (eight GPs, including two salaried) and had recently employed a highly qualified manager who took overall responsibility for ensuring that targets were met. They pride themselves on their track record of providing well organised care, and had devolved a great deal of the QOF-related work to their nurses.
Practices allowed researchers to observe meetings, hang about at coffee times and in reception areas, conduct formal and informal interviews, administer questionnaires and (in England) to observe patient consultations. No prior assumptions were made about the relevance or otherwise of practice activities, so that the approach to data collection was relatively open ended. Observation took place over a period of approximately five months in total, with the researchers spending an average of two to three days per week in the field, although this varied across the research period. A total of 37 formal audio-recorded interviews were conducted, including all but one GP (one GP in Big practice had multiple outside commitments and so was unavailable for interview), practice managers, senior receptionists, IT staff and healthcare assistants, and a variety of meetings were observed in all the practices. Every visit to the practices was regarded as an opportunity for informal observation. Observation in meetings and in more informal settings focused upon the new work required to meet QOF targets and the ways in which this new work was incorporated into established practice structures, processes and routines. Observation in consultations (where this was possible) focused on the integration of QOF-related work into consultation routines. Interviews were guided by flexible topic guides and focused upon attitudes to QOF and upon the interviewees’ beliefs about its impacts on the practice, including the impact on their working routines and on the nature of their role. Similar subjects were addressed with all professional groups, suitably adapted to cover relevant aspects of their role in the practice. Detailed fieldnotes were taken during all observation periods, and analysed alongside interview transcripts. Both fieldnotes and transcripts were read and reread by the fieldworkers in each team, and the two teams of researchers (England and Scotland) met at intervals throughout the project period to discuss emerging themes and interpretations, sharing the results of the ongoing analysis and feeding new ideas into the analytic process. The two teams of fieldworkers kept in email contact. An iterative approach to data analysis was taken, with constant testing and refinement of themes and ideas that emerged from the data, both back in the field and in discussion between the researchers (within and across the two teams). A feedback meeting was held in each practice, at which the ideas that had been developed were discussed with the participants, whose responses were treated as further data to be analysed as well as offering a degree of respondent validation. The overall questions raised and the focus of the analysis in both studies were the same: how were the practices responding to the QOF in practice? What were their expressed attitudes to the QOF both formally (in interviews) and in informal conversation? The results reported below represent a synthesis of the information obtained from interviews and from fieldwork, with quotes being chosen to illustrate particular points.
Responding to the contract – moving towards a more biomedical form of practice?
Although there were differences between the practices in the precise organisational solutions they chose to enable them to meet the QOF targets, the end results were very similar in all four cases. We thus observed changes in all the practices that will result in patients experiencing a more biomedical, disease-orientated type of care. First, we observed the development of increasingly sophisticated and comprehensive systems of patient call and recall. Whilst practices had previously operated limited systems of this kind, in all four cases these had been greatly developed and extended in response to QOF. Thus, patients with a wide variety of diseases received regular letters inviting them to visit the practice. Non-attendance in response to these invitations resulted in two follow-up letters. Despite QOF's provisions for ‘exception reporting’ described above, our practices did not regard non-attendance in response to these letters as a decisive expression of dissent, and followed up with phone calls and, in some cases, with home visits. As this doctor put it:
Our patients historically have got a really high DNA [‘did not attend’] rate and that's, that's always been the case ever since we've been here. It's the kind of population we deal with, but they don't mind being called up and they will come eventually so I think the thing is not to be put off by one or two non-attendances, just plug away and learn ways of getting hold of them. . . . and that's why we do odd evening clinics, Saturday clinics, we do other things to try and get them in, in different ways and sometimes, you know, if they won't come in then we go out to them. So we have got, we have got true house-bounds, but if there are other people who are ill with conditions who've for whatever reason won't, or don't come in eventually a trained nurse and an auxiliary will go out and do it . . . so there's no escape (Executive GP partner/Medium).
Such systems have the potential to place a burden on the patients concerned, particularly those with more than one medical problem who may receive multiple letters calling for them to attend several different clinics. They also represent a move away from a traditional system in which patients themselves are free to decide when they wish to attend. Patients are being constructed as passive, disease-bearing objects who need to be prompted and reminded to attend for care, or visited at home if they do not respond. Furthermore, groups of patients with similar conditions are assumed to require standardised patterns of appointments and follow up, with little space for personalisation within an automated system. There was some understanding expressed in interviews that being called to the practice might not be experienced as an unequivocal benefit, but this was constructed as the patients not really knowing what was in their best interests:
I mean, some people, I mean, I suppose there's a percentage that don't want to come in and don't attend but I think it's good, see, I feel it does the patients good and I think probably for the, I mean, I suppose there's one angle you could say, well, you’re maybe making them think about their illness more often, because they’re coming back and forward to you when, and some people would probably like to not think about it (Practice nurse 3/Modern)(authors’ italics).
Secondly, participants from all our practices acknowledged that there had been some changes in their own consultations, as they ‘fitted in’ the extra elements required by QOF:
Many of these things I might have been doing anyway, as part of the way I think about each consultation, but I am probably more systematic now, because there are more computer prompts suggesting what you do. I've got an embossed card on the front of my desk, reminding me of what all my targets are (GP 1/Modern).
Finally, it was clear both in interviews and observations of staff at work in the practices that they were trying hard to meet the targets. These targets are clinically demanding, and so it seems that, post-QOF, patients are likely to be receiving more medication than they did in the past, and indeed more than they seemed to desire:
Some patients will come to you and they’ll plead with you, ‘please don't give me any tablets, I’ll bring my blood pressure down, I’ll do everything, I’ll bring it down’, and again they’re not horrendously high they’re like say 146/90 or whatever . . . but we’re saying to them ‘well, look we've checked it three times now and it remains raised you’re clinically classed as hypertensive, we follow these guidelines and this is what we should be doing with you’ (Nurse practitioner 1/Medium).
Observation of practice meetings provided further evidence of an increase in the amount of drug treatment being offered to patients, as staff discussed the increases in the volume of prescriptions being issued for drugs used to reduce cholesterol and blood pressure.
In summary, we found from both observation and interviews that real change has occurred to the care that patients receive in all our practices. Structures, processes, consultations and clinical practice have all changed in the direction of a more biomedical model of care.
Claims to holism
Despite this shift towards more biomedical forms of practice, the GPs in our study continued to claim that little had changed in their practice. This doctor's summing up of what general practice is all about was typical, and closely follows the rhetorical claims made in the literature identified earlier:
Hospital medicine can go more on the biological factors to the neglect of other aspects. We’re much more aware of other dynamics going on including social, financial problems, housing market, stress, others. All these can be part and parcel of the consultation. We’re very much on board with that (GP 15/Big).
QOF was routinely presented as introducing change at the margins, and as being mainly about improving practice organisation and recording behaviour:
All I think QOF did was just make it a bit more organized and that. I don't think it was anything new (GP4/Modern).
‘Being paid for what we do already’ was also a commonly recurring theme.
We identified three overlapping discursive strategies that were used by participants to maintain their claims to holism in spite of the observed shift towards more biomedical practice. First, the doctors in our study argued that, whilst overall the practice had paid attention to addressing biomedical issues, they were able to maintain a ‘patient-centred’ focus in their consultations that was in keeping with the traditional values of general practice. This doctor argued that they had avoided the dangers associated with QOF:
I don't believe we've done that I think we still have the consultations that are much more to them then just tick boxing. . . . so I think we've managed not to become just a tick box practice. I don't think we ever were and I think this [QOF] has correctly upped the anti on good clinical practice without us falling into that trap (GP 3/Medium).
The following GP, whilst recognising some disadvantages, was enthusiastic about QOF:
. . . I think [QOF is] a fantastic idea really. I mean it's very mechanistic and everything, and that has its disadvantages. But you know, for the first time it seems to me it's brought quality into the framework for GPs. We’re now paid for quality and so you find much more doctors doing quality because they’re being paid for it (GP 12/Big).
However, when talking about the core values associated with general practice, the same GP fell back on the rhetoric of patient-centred practice within the consultation, in spite of the fact that QOF, which she welcomed so whole-heartedly, implies an approach which pays no attention to patients’ perceptions or knowledge:
[it's] a good thing if we have more respect for the patient's agenda and the patient's perception really. And this whole business about the idea about lay knowledge. Which I never used to really understand and you know, didn't tend to have too much respect for. But I think as time goes by, you realise that actually quite often the patients are right in their perceptions (GP 12/Big).
Others emphasised that they could maintain holistic care by being aware of the wider context of their patients’ lives:
So I think now maybe you've got two agendas one is the, you know, the black and white patients physical health you know and one is the social, spiritual, personal help isn't it really, . . . you know, relationship health but no I think it's ok, I think we've, I think proportionally we've got things in the right proportion (GP 4/Medium).
The following doctor, whilst overall fairly enthusiastic about the new contract, emphasised both holistic credentials and a desire to resist any pressure to change the focus of the consultation:
. . . . My top priority is dealing with what the patient has come in with and if I have time I will do their smoking status and their blood pressure. Now you could argue well this is probably more important than what they have come to see you about, but I just feel that I would find it difficult to work in that way (GP 3/Family).
Thus, our respondents claimed that being ‘patient-centred’ within the consultation served as a defence against the biomedicalisation inherent in QOF. A second discursive strategy employed by our GP respondents was to argue that their nurses were doing the routine medical work necessary to meet targets, leaving doctors free to deal with more complicated problems. They were thus protecting their own holistic practice by delegating less highly skilled work. This doctor's comment was typical:
The nurses are very good at doing things and following criteria, so everybody knows they are always very good at achieving what has got to be achieved, and in some respects this is why many practices I know will say ‘No, doctors have nothing to do with the contract – we just give it all to nurses’ (GP 4/Modern).
Other GPs took this further, arguing that not only were they delegating the ‘medical’ work to their nurses, but that the ‘complex’ work that they retained was more difficult:
The chronic disease nurses are a great help. They have checklists and templates so they don't forget things. I actually think they’re better at it than we are. They’re a bit more blinkered than we are. We’re such generalists we don't stick to the narrow things we go off looking at all sorts of things. I'd encourage nurses to develop specialist skills. I'm definitely in favour of it. . . . We are dealing with very complex problems. The magnitude of them. They go to the nurses for routine screening. Screening is what the nurses are doing (GP 15/Big).
It is notable that this respondent describes GPs as ‘such generalists’, echoing the RCGP differentiation between holistic GPs and ‘the other’ of specialisation.
Finally, and linked to the notion of complexity, some of our respondents also claimed a kind of holism that was based upon ‘having an overview’ of patient care in the practice rather than being involved in all the details.
I think, I think what we’ll be doing is a little bit what we've started doing here in the sense that I don't see half as many patients as I used to but I'm still looking after probably more patients than I used to because I've got 3 nurse practitioners and a practice nurse seeing patients on my behalf if you like, so a lot of my mornings are spent not only seeing patients but flitting around other rooms seeing other patients and the patients I see now tend to be ones referred on by nurse practitioners, truly complicated patients. So it's almost like a consultant-registrar system and I see that happening I see, so I see probably fewer GPs at the top level, nurse clinicians, practitioners, whatever we end up calling them with practice nurses doing the chronic disease monitoring and a heavy use of nurse auxiliaries underneath that, em . . . so it's a real sort of pyramid structure (Executive partner/Medium).
Furthermore, for this doctor ‘having an overview’ of the patients’ care is seen as more important than developing personal relationships with them:
I still think it's important that patients remain essentially at one place so that continuity of care in some way, shape, or form is established because even in a system like ours which is heavily delegated down although I might not see patients, I know about the complicated patients that are going on so if I'm called to see one I know exactly where they’re up to, so somebody has got an overview of it (Executive partner/Medium).
The following doctor took a similar view:
I will say that right from the start, I basically feel that my role as a GP is to look after the patient overall and I feel that the GP has the overall responsibility for that patient's health. So really, I see us as I suppose more and more co-ordinating here, making sure the patient gets the care whether it is from practice nurse or hospital or whatever. I suppose in times gone by we did a lot more of the actual hands-on stuff ourselves, which we are probably not doing so much of now but we are still there in the background, basically taking the responsibility even for people that don't see us very much and who tend to visit the practice nurse more than us (GP3/Family).
In summary, therefore, the GPs in our study practices continued to make discursive claims that they provided holistic care in keeping with the traditional values of general practice. These claims varied in substantive content, but centred upon three areas: a metaphorical ‘protected space’ within the consultation, in which they continued to be patient focused in spite of other pressures; an ideal of complexity that contrasted complex, generalist, patient-centred medical work with more routine, specialised, medically-focused work done by nurses; and the maintenance of an overview of patient care that allowed them to claim knowledge of the whole.
The implications of our study, if at all widely applicable, are considerable in terms of the content of medical practice and medical discourse. This was a small study, and as such vulnerable to the possibility that our practices were in some way atypical. However, the overall high QOF scores obtained by GPs in the first year of the contract (an average of 91% of available points, rising in the second year (Cole 2005)) suggest that other practices were adopting similar measures to those that we observed. Furthermore, our four practices, although all relatively high scoring, were very different in size, ethos, population served and organisation, suggesting that our findings may well have wider resonance. It is also worth noting that there is considerable international interest in QOF and its impact (e.g. Mangin and Toop 2007).
These findings can be summarised as follows. First, we identified a real shift towards the delivery of a more biomedical, disease-orientated model of care occurring in response to the imperatives embodied in the new GMS contract. GPs’ traditional self-identification as ‘holistic’ or patient-centred practitioners has been challenged on the grounds that ‘biopsychosocial medicine’ is ‘the old [biomedical] model with gloss’ (Armstrong 1987: 1217), and that GP commitment to it is more rhetoric than reality (Dowrick et al. 1996). However, even if GPs have never been truly holistic in their approach, our study demonstrated changes that go further in the direction of a biomedical, disease-orientated model of care than has been seen before. This process can perhaps be seen as mirroring the historical rise of the discipline of hospital medicine and the decline of the notion of the ‘sick man’ (Jewson 1976). As occurred in 19th Century hospitals, patients in modern general practice are increasingly being identified by disease labels, and their care is being determined by those labels. Our historical account of the postwar development of the distinctive identity of the general practice discipline shows that claims to holistic practice were important in the 1960s and 1970s as the means of establishing the professional credentials of GPs and in enhancing their status with respect to their hospital colleagues. Before this, GPs sought to maintain their professional status by maintaining a foothold in hospitals via admitting rights and appointments as ‘clinical assistants’ (Armstrong 1979). Contemporary developments may again be mirroring the past; the current move of many GPs to become community-based specialists (GPs with a special interest, or GPwSIs) (Rosen et al. 2003) can be seen as a similar strategy.
Secondly, in spite of the real changes occurring in their practices towards a more biomedical model of care, the doctors in our study seemed unaware of this, denying that significant change had taken place and locating any change at the margins of practice. They maintained discursive claims to holistic practice, using a variety of different arguments to demonstrate how they continued to care for ‘whole people’. It is therefore clear that there is a disconnection between discursive claims about the nature and purpose of general practice and actual practice. On the whole our respondents did not show evidence that they were discomforted by this disconnection, or even noticed it, and expressed overall satisfaction with life post-contract. Although it might be argued that the financial rewards associated with the contract render any such discomfort easy to bear, the practices that we studied spent a great deal of the additional income from the contract on new staff and information technology. Our respondents had not therefore taken large pay rises, rendering it unlikely that their enthusiasm for meeting targets stems entirely from financial motives. Indeed, evidence from other studies confirms that that even where targets cost more to meet than they bring in rewards, doctors retain their enthusiasm (Marshall and Harrison 2005). Our findings provide something of a contrast with those of Charles-Jones et al. (2003), who, in a study undertaken before the new contract, found that GPs were positioning themselves as being more concerned with biomedicine, delegating other concerns to nurses. Like them, we found evidence of increasing biomedicalisation and delegation to nurses, and some evidence of doctors using this to bolster their claims to professionalism. However, rather than using this to reconfigure themselves as narrow, biomedical specialists (as Charles-Jones et al. suggest), our participants argued that this delegation left them free to deal with complex problems in a holistic way. This illustrates a further point about GP identity claims. As noted above, in spite of the ubiquity of GP claims to holism and patient-centredness, definitions of what this means in practice have remained vague and slippery. Patient-centred consultations, management of complexity and concern for social and psychological issues are all present in the literature as surrogates for holistic care. In the wider field of medicine and health, more and different definitions are evident, with nurses drawing upon a discourse of caring (see for example: Williams 2000: 55, Timmons and Tanner 2004), and practitioners of alternative medicine defining holism in ways to suit their own ontological perspectives (Freeman 2005, Norris 2001). In our study we found that this definitional slipperiness provided space within which clinicians could continue to claim holism whilst engaging in working practices based on a quite different philosophy.
Thirdly, our GPs’ continuing espousal of holism is in line with wider contemporary survey evidence about GPs’ espoused values (Hasegawa et al. 2005). The preceding points, however, raise questions about how far the official representatives of general practice (such as the RCGP) will be able to continue to represent the discipline in terms of holism defined in contrast to the ‘other’ represented by specialised hospital medicine. It will be interesting to observe over the next few years whether the official rhetoric of general practice shifts to take account of the practical changes that we observed. The most recent statement from the RCGP about the curriculum to be studied by general practice registrars (http://www.rcgp-curriculum.org.uk/rcgp_-_gp_curriculum_documents/gp_curriculum_statements.aspx (accessed March 2007)) continues to espouse holism and patient-centred practice, retaining a sceptical tone towards the biomedical model. Registrars following this curriculum may well find a contradiction between this rhetoric and their practical experiences during placements of the bureaucratic systems set up by practices to ensure that patients comply and targets are met, whilst rank and file practitioners may feel that their professional elite are becoming too far removed from the reality of practice on the ground. In a study of young non-principal GPs, Jones and Green (2006) found that these (relatively newly qualified) GPs were more likely to define professionalism in terms of technical competence and good communication than by reference to holism or biopsychosocial medicine; whether this represents a real change that will become manifest in the profession at large over time, or whether it is a consequence of these doctors’ relative inexperience that will alter as they grow older remains to be seen. If it is a real change, then we may be witnessing a significant shift in the rhetorical definition of what makes a GP a professional; a shift in which the ‘professional elite’ would seem to be following rather than leading.
Finally, our study concentrated on the viewpoints of practitioners and staff. No attempts were made to examine the patient experience, and we can therefore only infer what the changes that we witnessed might mean for patients. Conrad describes medicalisation as: ‘defining a problem in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem, or using a medical intervention to “treat” it’ (Conrad 1992: 211). Certainly, it would seem that in 2007 patients were likely to be experiencing a more medicalised (in Conrad's terms) form of care than in the past: for example, the new QOF indicators of 2006 introduced an entirely new disease, ‘chronic kidney disease’, whose nature, significance and prognosis remains unclear (Hallan et al. 2006). The dangers of increasing medicalisation of the population are recognised in the medical literature (Leibovici and Lievre 2002, Williams 2001), but our GP respondents generally failed, unless prompted, to consider the overall experience of a patient attending the practice in the post-QOF, more medicalised, world, concentrating instead upon what went on in their own consulting rooms. It remains to be seen what the impact of this will be as QOF further grows and develops.
The English arm of the study was funded by the National Primary Care Research and Development Centre. The Scottish arm was funded by the Economics and Social Research Council and the EastREN Primary Care Research Network. BG was funded by the Health Foundation and the Chief Scientist Office of Scottish Executive Health Department. We are grateful to our participants who welcomed us into their practices and who were very generous with their time. We are also grateful to Guro Huby, Francis Watkins, Huw Davies and Martin Marshall who contributed to the design and conduct of the study. Two anonymous referees provided comments on a previous draft, which were very helpful in the development of this paper.