Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Sadly, what do you expect?
- Mark W Couldrick (28 August 2008)
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Author should think again
- Graham Wheatley (31 August 2008)
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The truth is out there, however inconvenient
- David Oliver (2 September 2008)
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Out where?
- Graham Wheatley (3 September 2008)
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Cross Purposes
- David Oliver (5 September 2008)
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Focus and clarity on using evidence to improve care performance
- Graham Wheatley (7 September 2008)
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Mark W Couldrick, GP Partner Devon EX15 3SF
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Since at least 30% of a practice's income depends on the Quality and Outcomes Framework it is impossible for a practice to stay viable and not direct significant resources to fufilling the requirements. Things that are easy to measure are most suited to a target based culture. Complexity falls by the wayside. Exception reporting is heavily performanced managed by PCTs often with self-selected professional input offering advice based on opinion not neccessarily as sophisticated as Dr Olivers. Struggling to navigate the metrics deemed important by the government whilst practicing humane and professional medicine is a constant struggle. Competing interests: General Practioner working under PMS contract in practice employing 30 staff whose ongoing employment depends on following the edicts of the contract |
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Graham Wheatley, GP Munro Medical Centre, West Elloe Avenue, Spalding PE11 2BY
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Dr Oliver makes some unusual statements in his letter which would on the face of it seem to be informed more by his own peculiar personal prejudice than by any evidence from, or understanding of, general practice. He shows a basic error in logic in comparing the “many” admissions in older people due to iatrogenic illness caused by polypharmacy to a rise in primary care prescribing, as if there is self-evidently a causative link. Many factors influence prescribing decisions, not least the wider indications for statin and ACEI prescribing for older people in recent years, and a greater awareness that older people should be given the opportunity to benefit from effective interventions where appropriate and where they do not cause disproportionate adverse effects. His argument is a bit like saying that, as crossing the road may be hazardous, all further attempts at crossing the road should be condemned. When he states that “treatment … doesn’t take into account … side effects”, he’s clearly unaware that QOF exception reporting takes exactly that into account. It's unclear what evidence, if any, supports his contentious view that it is “doubtful” that medication reviews “stimulate meaningful risk benefit analysis and rationalisation of medicines”. He seems ignorant of the fact that many people aged over 65 are included in QOF areas such as COPD, diabetes and CHD. conditions which (he would presumably agree) cause significant morbidity in older people far more than in just "the young and middle- aged". To say that in general practice anything not in QOF “doesn’t tend to happen” shows how little Dr Oliver understands general practice - for the majority of practice activity will be about activities other than QOF. If he wants general practice to do even more, the answer is that lots can be done in general practice – but if you want assurances that new activities will performed to a measured and verifiable standard (as QOF is) then that will have to be funded - as QOF is. There needs to be a move away from the currently fashionable fiction that only hospital services deserve increases in funding, particularly when some of these services are highly cost-inefficient compared to equivalent (and often better) services carried out in general practice. Dr Oliver clearly disapproves of the entrepreneurial model, but he's wrong to suggest that this has nothing to offer older people. GPs might more often though prefer to call it innovation, motivation and success at getting things done on time and within budget - something which surely is exactly what the care of all people, older people included, needs. Competing interests: None declared |
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David Oliver, senior lecturer, geriatric medicine University of Reading, School of Helalth and Social Care
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Sir I thank Dr Wheatley for his comments. I should preface my reply by pointing out that at no point in my letter did I advocate increasing funding to secondary care, nor did I set out to denigrate the excellent work done by hardworking staff in primary care. I spend a lot of my own working life working closely with primary care to help deliver better joined up services for older people and am well aware of the pressures and difficulties that GPs and community nurses face. Nor would I deny for one second that conditions such as heart failure and COPD are just as relevant to the care of older people. However, we need to differentiate imagined critcisim of individual practitioners from the criticism of a performance framework which can distort priorities. We also need to differentiate objective evidence from assertion. It was not me but an academic department of primary care (Steel N et al BMJ 2008) who published the survey of over 8,000 patients showinig that conditions affecting older people were systematically less well recognised and managed than those affecting younger people and that the influence of the QOF was partially responsible. It was not me but a GP (Bayly) who was first to respond to Steel's paper citing clear evidence of poor recognition and management for patients with falls, fractures and osteoprosis and again recognising the QOF as a key driver to improve this and that so far attempts to incorporate. It was also not me but the Royal College of Physicians, who produced recent major national audits of falls and bone health and continence care showing an appalling level of recognition and management of these problems. (Despite there existing NICE guidelines for all three which are blatantly ignored by PCTs). Nor was it me who produced the dementia or stroke strategies - again recognising systematic deficiencies in care. (And yes, secondary care organisations are equally culpable). With regard to medicines prescribing there was an independent report in August in the BMJ clearly outlining the increase in prescribing for older people. And a paper (again by a GP - Dr Zermansky Age and Ageing 2007) who reviewed prescribing in care homes and was able to reduce costs by 30% as well as adverse events such as falls by reducing long-term and no longer indicated prescriptions. Zermansky and colleagues concluded that "the QOF standard for medicines review does not stimulate meaningful reduction of prescriptions" The data on iatrogenic causes of admission to hospital and inappropriate prescribing are all out there in peer reviewed journals and any hospital physician on call on any given day will admit patients on inappropirate polypharmacy. The problem with "clinical exceptions" is that patients generally recruited in trials of say hypertension or cardiac failure are younger, less frail and with less co- morbidity than the type of patients frequently admitted to hospital so that the pressure to treat these conditions aggressively may cause inappropriate polypharmacy in frail older people with poor functional reserve. I return to the point I made in my original letter. Frailty, dementia, incontinence, falls, fractures, stroke, dementia and multiple long term conditions are prevalent and debilitating problems responsible for much human misery and for a high percentage of the "high intenity users" admitted repeatedly to hospital, not to mention the 500,000 care home residents for whom medical input is patchy and often focussed on crisis response. Getting the care of older people with such conditions would be win/win for them and for the whole system. But because these aspects of care do not have a performance incentive attached - partly due to ageist values and partly because they do not lend themselves to a simplistic action and metric, we have a situation where the care of the biggest group of service users is relatively neglected, as Steel et al elegantly demonstrated. Something needs to change and responding by denying that there is even a problem is an abrogation of responsibility David Oliver Competing interests: None declared |
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Graham Wheatley, GP Munro Medical Centre, West Elloe Avenue, Spalding PE11 2BY
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I would agree with Dr Oliver that it’s necessary to distinguish between "objective evidence and assertion”, which makes it all the more puzzling why his main assertion (than the QOF "does nothing to improve the care of old people") is apparently not supported by the evidence, objective or otherwise, from the authors he chooses to quote. Examination of these quoted papers is instructive. He attributes to Steel et al (BMJ, 2008)1 the finding that: “conditions affecting older people were systematically less well recognised and managed than those affecting younger people and that the influence of the QOF was partially responsible”. What they actually reported was the following: “Performance monitoring through the general practice pay for performance contract has been linked with improved care for included conditions. Making information on performance available for a wider range of conditions is an essential component of quality improvement. Including more conditions that affect the quality of life of older people in future revisions of the general practice contract is one way to do this and has the advantage that the infrastructure is already largely in place” Steel et al thus presented QOF as a positive means of improving performance, one they felt should be extended by “making information on performance available for a wider range of conditions”, rather than the attribution made by Dr Oliver, which was essentially negative, viewing QOF as the reason the care was poorer in the other conditions - something the authors specifically did not claim. Bayly (another rapid responder quoted by Dr Oliver) in fact argued for the QOF to be extended, something Dr Oliver himself belatedly acknowledged. Perhaps the problem is one of perspective - is QOF a glass half empty, or half full? There is common agreement amongst the authors Dr Oliver turns to that the QOF is a positive force for improved standards, that should be extended to new disease areas by formulating and agreeing what is meant by improved performance in a way that can be measured or otherwise validated. Far from QOF being the problem, it is the solution, and it should be extended, they say. Oliver quotes a study by Zermansky in Age & Aging 2007 (actually 2006) (2), apparently stating that they were able to reduce costs by 30% (actually the paper stated there was “no ... significant change in drug costs”). Dr Oliver states that the authors concluded “the QOF standard for medicines review does not stimulate meaningful reduction of prescriptions”. In fact, the paper does not contain this statement (or any like it), perhaps unsurprisingly as the research was carried out in 2002 - before QOF started. Zermansky was later concerned that he had not obtained adequate consent from the patents for their medication to be reviewed (3). Dr Oliver goes onto state that “any hospital physician on call on any given day will admit patients on inappropirate polypharmacy”; it would be equally possible to say that GPs on any given day will find hospital discharge letters showing medication erroneously added or discontinued. He fails to show evidence linking iatrogenic admissions to QOF related “inappropriate polypharmacy” - apparently though he just knows it’s true. Which reminds me of Dr Oliver’s title - “The true is out there, however inconvenient”. Al Gore’s film “An Inconvenient Truth” was criticised by a High Court judge as having 9 significant factual errors, unsupported by evidence or even consensus. The TV series “The X-Files” used the catch phrase “The truth is out there” to describe the characters’ profound belief (in the absence of evidence) that UFOs did in fact exist. One would expect a more credible approach than this to medical debate! 1 Nicholas Steel, Max Bachmann, Susan Maisey, Paul Shekelle, Elizabeth Breeze, Michael Marmot, and David Melzer Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England BMJ 2008; 337: a957 2 Age and Ageing 2006 35(6):586-591; doi:10.1093/ageing/afl075 3 BMJ 2005;331:1271-1272 (26 November), doi:10.1136/bmj.331.7527.1271-c Competing interests: None declared |
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David Oliver, Senior Lecturer, Geriatric Medicine University of Reading, School of Health and Social Care
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Sir Dr Wheatley is right in that as someone trying to knock out a quick response in an online exchange which will never be published in the paper journal in the ten minutes before I started my ward round, I had neither the time nor the inclination meticulously to reference every statement I made and that I mis-quoted Zermansky from memory. (Though I spoke to the doctor in question at a recent conference where he was very clear about the bluntness of the QOF as an instrument for stimulating rationalisation of medication). I am also familiar with the principles of evidence based medicine and might have even published the odd systematic review here and there. However, I dont write a provocative letter as a densely referenced systematic review. More to the point both Dr Wheatley and I are partially ignoring the contents of one another's letters for the sake of robust debate. So....just to be clear. a) I have no animus against primary care physicians nor any doubt that
they do an outstanding job.
So my questions are simple i) Does Wheatley deny that these conditions are relatively neglected
and relatively badly managed?
David Oliver Competing interests: None declared |
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Graham Wheatley, GP Munro Medical Centre, West Elloe Avenue, Spalding PE11 2BY
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In the heat of the moment it’s easy for anyone to get things wrong and Dr Oliver deserves credit for ‘fessing up as generously as he has. I’d recommend Google for when time is short as a surprisingly quick and easy way of pinning down full text versions of specific papers. There are though still some areas that would be worth clarifying in the argument about the impact of QOF on elderly peoples’ health. Dr Oliver states that “it is nonsensical to argue that on the one hand the QOF levers up quality for those areas which it highlights as targets but then on the other hand to suggest that this doesnt divert attention away from equally other important areas of care.” However, this would only be true if the total outputs from general practice had to remain the same. In fact, modest additional new contract funding has both funded and incentivised additional staff time and effort to carry out the new evidenced-based work in QOF. This is shown clearly in the increase in the amount the average GP spends on practice expenses (mainly staff) between 2002/3 and 2005/6 of over 21% (1). Where outputs have increased, extra QOF work does not mean that other important general practice work has been neglected. To show that QOF “caused” the “relative neglect” of some areas of elderly care, it would be necessary to show an association between QOF and reduced care standards in the relevant areas that took place over time – with care being better before QOF and worse after. No such association has so far been shown by Dr Oliver. In fact, the quoted authors themselves concluded that to improve care in the relevant areas, QOF should be extended into those areas. QOF was seen by those researchers to be a positive force for improved standards, not a negative force that makes care worse. Dr Oliver lists a variety of areas of care (eg. incontinence, falls, bone health) where care is currently “substandard”, suggesting that these are conditions “which per force must be managed largely in primary care”. Perhaps not Dr Oliver’s fault, but nothing is guaranteed to irritate GPs more than when told unilaterally by others that (a) large and growing areas of responsibility are now primarily their concern, (b) no new funding is necessary to carry out this work, and (c) why isn’t it done already (to externally imposed standards that may or may not be realistic)? There may well be areas of care (particularly for elderly patients) where, if time and resources were made available, GPs could help. I’d also suggest that the evidence shows that to do this, frameworks of standards would need to be agreed and funding allocated, perhaps on the basis of how well practices or other organisations met those standards – a bit like QOF, in other words. There’s little doubt that QOF has improved care (particularly preventative care) in important disease areas that disproportionately affect the elderly, such as coronary heart disease, strokes, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, heart failure, diabetes, hypertension, hypothyroidism and depression. It’s to the great credit of practices that despite the significant real-terms funding cuts over the last three years, these health benefits have been not just maintained but improved and already extended into new areas. Rather than attempting to dismantle this success, Dr Oliver perhaps should be working to help extend it further into new areas of care where performance might be better and where GPs’ skills are of use – as long as funding follows any new responsibilities. Dr Oliver acknowledges errors but still has a surprisingly strong sense of self-belief in the certainty of his cause concerning QOF and its effect on the elderly, particularly so when considering that the evidence would so clearly seem to point the other way. I’d like to extend my hand to him, to help him up the steep slope of scepticism and up onto the bright sunny plateau of improved care success that a well worked out clinical performance system (such as QOF) can provide. (1) http://www.ic.nhs.uk/statistics-and-data-collections/primary- care/general-practice Competing interests: None declared |
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