O modelo de pagamento por desempenho e sua influência nos princípios e
            prática dos médicos generalistas britânicos

Norman, Armando Henrique; Russell, Andrew J.; Macnaughton, Jane

doi:10.1590/0102-311X00149912

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ARTICLE • Cad. Saúde Pública 30 (1) • Jan 2014 • https://doi.org/10.1590/0102-311X00149912 copiar

O modelo de pagamento por desempenho e sua influência nos princípios e prática dos médicos generalistas britânicos

Autoria SCIMAGO INSTITUTIONS RANKINGS

Este artigo explora alguns efeitos do modelo de pagamento por desempenho nos princípios e prática dos médicos generalistas britânicos, podendo contribuir para o debate sobre a relação entre modalidades de incentivos financeiros e qualidade dos serviços na atenção primária à saúde em países de moderada e baixa renda. Objetivando investigar o que os médicos generalistas têm a dizer dos efeitos do pagamento por desempenho britânico sobre seu ethos profissional, conduzimos entrevistas semiestruturadas com 13 médicos generalistas, educadores e líderes no meio acadêmico da medicina no Reino Unido. Os resultados apontam um modelo de prática mais biomédica e fragmentação do cuidado, com enfermeiras e outros profissionais mais focados em doenças específicas. Houve também um aumento da medicalização da vivência dos pacientes, pela rotulação e tendência a prescrever mais medicação e menor uso de intervenções não farmacológicas. Assim, o pagamento por desempenho britânico tem gradualmente fortalecido um modelo científico-burocrático de prática médica que teve efeitos profundos sobre a forma como a medicina de família vem sendo praticada no Reino Unido.

Medicina de Família e Comunidade; Remuneração; Medicina Geral

Components of total points score	Points	Way in which points are calculated
Clinical indicators	655	Achieving pre-set standards in management of:
		Smoking Coronary heart disease Heart failure Atrial fibrillation Stroke and transitory ischemic attack Hypertension Hypothyroidism Diabetes (Hb-1c) Chronic kidney disease Dementia Learning difficulty Depression (PHQ-9) Mental health Chronic obstructive pulmonary disease Asthma Epilepsy Cancer Obesity Palliative care
Organizational	181	Achieving pre-set standards in:
		Records and information about patients Information for patients Education and training Medicines management Practice management
Additional services	36	Achieving pre-set standards in:
		Cervical screening Child health surveillance Maternity services Contraceptive services
Patient experience	108	Achieving pre-set standards in:
		Patient survey Consultation length
Holistic care	20	Reflects range of achievement across clinical indicators — calculated by ranking clinical indicators in terms of proportion of points gained (1-10). Proportion of the points gained by the third lowest indicator (i.e. indicator ranked 7) is the proportion of the holistic care points obtained
Total possible	1,000

Types of indicators	Explanation	Example
Yes/No indicators	All points are allocated if the result is positive and none if it is negative.	The Information Indicator 3 requires practices to have arrangements for patients to speak to general practitioners and nurses on the telephone during the working day. The practice must have a written policy on telephone availability and be able to demonstrate the arrangements if required.
Range of attainment	For most of the clinical indicators, it is not possible to attain 100% results, even if allowed exceptions are applied, so a range of satisfactory attainment is specified, which varies from 40% to 90%.	The Diabetes Indicator 5 asks practices to report the percentage of their patients with diabetes mellitus that have a record of HbA1c or equivalent in the previous 15 months. Three points are available with payment stages of 40-90%. If 65% of the practice patients do have a record of HbA1c within the previous 15 months, then the practice will receive 25/50 (i.e. half) of the available points.
Minimum standard indicators	All points are awarded if the criterion is met in more than a certain percentage of cases.	The Records Indicator 18, worth 8 points, requires that a practice has up to date clinical summaries for at least 80% of patient records.

Number of the general practitioner	Sex	Years of working as general practitioner	Type of contract	Medical educational activity	UK regions
1	Male	> 10	Partner	Tutor	Northeast, England
2	Male	> 10	Partner	Researcher	East Anglia, England
3	Male	> 10	Partner	Continue medical education	Southeast, England
4	Male	> 10	Salaried	Continue medical education	Southeast, England
5	Male	> 10	Salaried	Teacher	Northeast, England
6	Female	> 10	Salaried	Researcher	Northwest, England
7	Female	< 10	Partner	Tutor	Northeast, England
8	Male	< 10	Partner	Tutor	Northeast, England
9	Female	> 10	Partner	Tutor; teacher	Northeast, England
10	Male	> 10	Salaried	Researcher; teacher	Scotland
11	Female	> 10	Salaried	Tutor	Scotland
12	Female	< 10	Salaried	Tutor; teacher	Scotland
13	Male	> 10	Partner	Researcher	Scotland

Research steps	Definition	Explanation
Participant selection	Snowball sampling	This strategy was developed and has subsequently been utilised by researchers as a solution to researching “hard-to-reach” participants, which is the case of general practitioners in Britain. It consists of ‘identifying a few potential cases of interest, verifying their interest, eligibility, as well as for accessing potential further cases via the initial participant’s social or professional contacts’.
Interviews	Semi-structured	Topic guide providing broad prompts to explore key issues derived from the literature and researchers’ own experience, focusing exclusively in general practitioners’ principles and practice.
Analytical method	Constant comparison	This technique basically involves iterative data collection and analysis divided into three phases.
Phase 1	Data reduction	The topics of interest are selected and extracted from the raw data (i.e. the interview transcript is “fragmented” and labelled).
Phase 2	Data display	The organisation of the “reduced data” in such a way that it enables a clearer understanding of it. As our sample was small it did not require any sophisticated “cognitive devices” to compare and to look for relationships and connections within the data.
Phase 3	Conclusion drawing/verification	This is a process of interpretation via the identification of patterns and anomalies which is re-interpreted, modified and even discarded to draw possible conclusions.
Result presentation	Narrative based approach	The selected themes were complemented by maintaining a broad “narrative” of each participant’s or case’s account.

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[1] Correspondence A. H. Norman Department of Anthroplogy, Durham University. Dawson Building, South Road, Durham, DH1 3LE, U.K. a.h.norman@durham.ac.uk