Thursday, 18 February 2010

The QOF Express

As the end of the tax year approaches, the race to meet our annual targets is on. Like squirrels gathering nuts the practice must collect as many QOF points as it can in order to get paid. It's not unlike those lucky contestants at the end of The Crystal Maze, scrabbling around in the wind for £5 notes. But whilst we engross ourselves in desperately trying to squeeze in any outstanding foot checks for the diabetics, breathing tests for the asthmatics and blood pressure checks for just about everybody, I can't help wondering what our patients must make of all of this?

What has struck me most is just how much we put them through. We expect them to oblige us by continuously appearing for blood pressure measurements, diabetic examinations, COPD checks, elderly care reviews etc etc and to cheerfully knock back as many medications as it takes to achieve the 'right' results. It's one thing if you've only got one medical condition to worry about, but for many patients, and perhaps most commonly for elderly patients, there are multiple problems meaning multiple assessments, blood tests and the like. Of course it's all well intended, but until recently I had never really considered the impact that all of this must have on their lives.

Mr Mitchell, an elderly gentleman and a prominent author, was recently diagnosed with atrial fibrillation (picked up incidentally when we dragged him in for a blood pressure check). For anyone who doesn't know, this is a relatively common irregularity of the heart's rhythm. As in this case, it often doesn't cause any symptoms, but unfortunately it does put you at a greater risk of having a heart attack or a stroke. Mr Mitchell was thus advised to start warfarin treatment, to thin the blood. He was referred to the warfarin clinic and bundled out with an armful of tablets. There wasn't much discussion, this was the best treatment for him and that was that. But Mr Mitchell has not taken his tablets, and he will not attend the clinic. In the several discussions that we have had on the matter since, he has made it quite clear that he would rather take his chances than become 'a patient'. He has no intention of swapping his independent lifestyle for one which must revolve around a multitude of clinics and blood tests.

Whilst from a medical viewpoint this may seem like the wrong decision, I do completely understand his rationale. It has made me wonder how much of our screening, interventions and health checks patients actually want? How much of our time do we spend getting so carried away with our efforts to treat a disease that we forget what we are actually meant to be doing; treating the patient?

Target driven health care does not help. The truth is that the majority of GP's pride themselves in treating the person and not the illness. It's what we specialise in. We know about patient autonomy and we know that the best treatment for one person may be very different from that for another. If we are lucky (and do not work in a polyclinic) we have the time to get to know our patients, making it easier for us to help them to make the right decisions. What QOF lead health care has done is place too much emphasis on results leaving little scope for tailoring care to the individual. It's robot medicine and it's not what we're about.


  1. I'm delighted to find one of my younger colleagues expressing these thoughts, which I share.

  2. "It's robot medicine and it's not what we're about".
    Actually, it shows a regretable lack of integrity on the part of GP's everywhere who take the (QOF) points and run - points mean prizes after all.

  3. I can't help wondering what our patients must make of all of this?

    I'm a patient with a QOFable disease. I'm in two minds about the QOF.

    Before QOF, GPs in several surgeries showed absolutely no interest in my disease or how I managed it (it's the kind of disease that takes constant daily monitoring and dose changing etc.). I did not get much in the way of monitoring blood tests. I was in a disease no-man's-land.

    After QOF, I started getting called in for annual monitoring blood tests but that was it really. I have the impression that the tests get done to meet practice targets rather than to improve my health. However, I benefit from having regular tests done because I can use the results of the tests to inform my own management programme.

    I have had experiences where I have been to the GP with an acute complaint but the GP spent 8 of my precious 10 minutes on their QOF targets and 2 minutes on the presenting problem. It made me feel like a walking QOF point!! I have found that locums/salaried docs are less interested in the QOF.

    I would prefer disease monitoring to be done in specialist hospital clinics where there is more time to help patients improve their health and less incentive to blindly follow QOF targets.

  4. "It has made me wonder how much of our screening, interventions and health checks patients actually want?"

    Oddly enough have spent a bit of time hanging round a forum recently discussing cervical screening. The women describe being harrassed, insulted and bullied if they don't want to be screened. Some have been removed from the GP practice list. Some describe attempts to screen them as virgins, or whilst under the recommended UK age of 25. Many of them have no intention of cooperating with cervical screening ever again, and avoid seeing doctors as much as possible due to the lack of respect for their consent and bodily autonomy. Unfortunately this tallies with my own experiences.

    There is general agreement in the discussion forum that much of the pressure is because, (please correct me if I'm wrong gentlemen!), that if you hit your cervical screening targets as a GP you get very well paid for it.

    Whilst it is important that women are offered the opportunity to screen, and every sexually active woman should give careful consideration to having it done, targets seem to have made this intimate examination practically compulsory, not necessarily to the benefit of the target population. It's not like it's the ONLY illness we get!

    But it's very nice to hear thoughtful GPs like yourself and the lovely A Fortunate Man discussing the problems targets cause. I'm sure, QOF or no QOF, your patients are lucky to have you.

  5. GrumpyRN - I wonder what makes you think we have a choice? Running an NHS GP practice without QOF payments is not financially viable. Putting finances aside, if we fail to perform on QOF targets we are branded by the PCT as poorly performing and harassed until we do better. Would you have us all become private providers?

    In response to anonymous 1 I think what QOF perhaps has achieved, as you say, is to make it less likely that patients with chronic diseases will be completely lost to follow up and never seen again. However I do believe that a much more preferable alternative to our bullying the public (as described by anonymous 2) is that patients choose to take responsibility for their own health, as it seems you have done. This allows patients to direct their care as suits them best and stops us breathing down their necks. It is unfortunately only achievable amongst the most motivated.

  6. QOF was good but it is a blunt instrument.

    Initially it helped to expose those practices who did not manage their patients well, but now that many of the worst practices manage to score over 900 points, by focusing their attention on ticking boxes, it no longer has much validity as an indicator of general practice quality.

    Which brings us to precisely how do you define quality in general practice and how do you measure it?

    My guess is that both GPs and patients know and can feel or sense a high quality general practice when they experience it, but have difficulty describing it, and of course no hope in hell of being able to measure it.