This site uses cookies.

Human Factors (HF) and QIPP: Part of the Solution or Problem? - Dr Mark Burgin

05/06/20. Dr. Mark Burgin BM BCh (oxon) MRCGP discussed how management theories are being applied to medical practice without monitoring, focusing on current favourites.

The toxic atmosphere in healthcare has been recognised for almost 2 decades and, despite for instance the very public problems with GP recruitment, little has been done.

Systems to measure the levels of toxic stress in healthcare settings, identifying safe limits and recognising and treating acute exposure are urgent priorities.

New theories are being applied to healthcare without proper assessment of whether they will reduce or worsen the toxic exposure to stress.

Human factors (HF) is based upon the idea that all systems make mistakes and relies upon awareness training to improve performance.

QIPP (quality, innovation, productivity and prevention) is a program from the Department of Health which tries to optimise productivity within the resource envelope.

The key objective in any system is to find the best compromise between delivering sufficient quality at a reasonable price and within a reasonable timescale.

It is not clear that either HF or QIPP help the health system will deliver on its key objective and there is concern that they may increase toxic stress.

Human Factors (HF))

The GMC has told doctors in training that they must ‘demonstrate and apply basic Human Factors principles’ to reduce error and influence behaviour. (1)

The GMC states that fitness to practice problems often lie within the nine domains of ‘generic’ professional capabilities and that training previously has been deficient.

The underlying assumption that all doctors are going to be leaders in education or management whilst ambitious is not likely to reflect most doctor’s trajectory.

Managers should share their insights with ambitious doctors but keeping up with clinical practice is difficult enough for most doctors.

Words like understand, demonstrate, reflect and promote are non-specific and only the phrase ‘raising safety concerns’ would directly improve patient safety.

Using imprecise language risks worsening the toxic atmosphere by imposing an excess of rules and a one-size-fits-all mentality that ignores doctor’s individuality.

The most effective method of improving HF would be to create a system that could measure and report toxic stress so that causes could be addressed.

QIPP (quality, innovation, productivity and prevention)

Few doctors would deny that improving quality, bringing innovation to practice, improving productivity and preventing illness are all good aims.

There are concerns that this program has been explicitly tied to achieve saving when all four require an increase in funding not a decrease.

Increases in productivity and preventing illness are generally achieved by increasing the use of a therapy e.g. reducing thresholds for treatment so will increase overall funding.

Ageing means that any savings from prolonging healthy life are wiped out by extending unhealthy life and more years taking preventative medication.

Real improvements to overall health can be achieved cheaply (exercise, smoking, alcohol, sugar, fat) but require social engineering rather than medication.

Transfer of funding from secondary to primary care would dramatically improve all four measures and decrease toxic stress by increased care in the community.

Developing New Management Models

There is an argument raging in healthcare management as to what value is, some saying that it is good medical outcomes, others that it is patient satisfaction.

The tension between these two ideas of value leads to toxic stress as doctor and patient are pulling in different directions.

In primary care the outcome most valued is biopsychosocial progress or more simply making progress in sorting the patient’s problems.

Some progress can be achieved quickly so patients and GPs alike feel rewarded whilst working towards the longer term aims individualised to the patient.

As GPs and patients work together to identify the aims that matter to the patient there is no difference between the medical outcome and patient satisfaction.

Any management model that does not incorporate at its core the concept of biopsychosocial progress will fail because it will separate the two.


Toxic stress damages patients as well as healthcare staff because like a toxic cloud of smoke it makes it more difficult to see mistakes and find solutions.

When doctors and patients have different ideas of value there is a tension that increases toxic stress and decreases rewards and damages QIPP.

Managers have a long history of inventing techniques which are damaging to the delivery of the health care in the western world, inter alia by causing toxic stress.

There has been little progress in management theories or Health and Safety action on toxic stress with the result that most doctors are burned out.

If used appropriately two of the more popular theories (HF and QIPP) have potential to turn the tide by monitoring toxic stress and transfer funding to primary care to relieve pressure on secondary care.

For the future it is essential that any new management model includes a measure of value that brings the individual and GP together e.g. biopsychosocial progress.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website

1. GMC 2017 Generic professional capabilities framework

Image ©

All information on this site was believed to be correct by the relevant authors at the time of writing. All content is for information purposes only and is not intended as legal advice. No liability is accepted by either the publisher or the author(s) for any errors or omissions (whether negligent or not) that it may contain. 

The opinions expressed in the articles are the authors' own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand. 

Professional advice should always be obtained before applying any information to particular circumstances.

Excerpts from judgments and statutes are Crown copyright. Any Crown Copyright material is reproduced with the permission of the Controller of OPSI and the Queen’s Printer for Scotland under the Open Government Licence.