Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The 'reality' of apparent improvements
- Peter W Ward (25 November 2008)
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More an Ostrich attitude than a Scottish one.
- Jessica R Harris (25 November 2008)
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Shifting Sand
- Des Spence (26 November 2008)
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Actually the ostrich is digging his own grave
- Andrew C Barnes (8 December 2008)
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What is the next step
- Charles Heatley (16 December 2008)
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Peter W Ward, GP Gateshead NE8 1NR
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It is natural those with vested interests in seeing the QOF succeed, the government, BMA and to a lesser extent RCGP and academics involved with its development, will want to boost it. I know I'm benefitting financially from it as are many of my GP colleagues. I do wonder though, how many of the apparent improvements are real. Just one example. In the first QOF one target concerned the diagnosis of heart failure. A certain proportion of patients with this diagnosis had to have had an echocardiogram to get all the points. It was quite possible to go through ones disease register relabelling the patients who had not as 'suspected heart failure'. An administrative exercise and more accurate diagnostic labelling yielding pretty much 100%. Treatment wasn't affected much though. I found this sort of thing with much of the QOF. I suspect many of the apparent improvements might be due to better admin and tighter diagnostic coding. Competing interests: None declared |
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Jessica R Harris, GP, Oxfordshire Eynsham Medical Group, The Surgery, 56 Churchill Way, Long Hanborough, Witney, Oxon, OX29 8JL
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I was sad to read Des Spence’s take on the quality and outcomes framework (QOF) in his recent column, it seems so nihilistic and unimaginative. At what point in his career did he decide to dismiss the findings of medical research, and what prompted this in such an intelligent man? I agree that there are other, crucially valuable aspects of general practice that aren’t easily measurable, but that doesn’t discount the value of the QOF. This is a case where we really can have our cake and eat it. British GPs are in the privileged position of being self-employed. We can organise our work as we see fit. If we find the QOF intrudes on already busy consultations then we have some choices. We could use the extra QOF money to increase the length of our consultations, in recognition of the increasing complexity of our work, and give more time to our patients. Or we could share chronic disease management with nurses and health care assistants, much loved by patients, and less likely to baulk at following protocols and guidelines. Or we could use the extra money to give the practice protected time to meet as a team and think outside the box about initiatives that might address the harder to reach aspects of inequality that he refers to. We don’t HAVE to get rich and grumpy. I suspect many GPs dislike the ‘nagging’ prompts and flags on their computer screens, and feel uncomfortable acknowledging that their actions can be manipulated so easily by cash incentives. But this misses the point. What matters is what we are being directed to do. If the QOF was sponsored by drug companies I’d be just as dubious as Des Spence, but, so far, it isn’t. It helps us implement evidence based medicine, and whilst the research isn’t perfect, it’s the best we’ve got so far. It just takes a different perspective to see that the QOF actually liberates us from cluttering up our brains with the relatively easy bits of the job, giving us space for the more skilful, thoughtful aspects. This means MORE time to listen to patients, not less. My problem with the QOF is the proposed move to develop locally agreed QOF domains. For me the QOF wins or looses on the rigor with which the domains are set up. They must be based on robust clinical evidence, with no room for political, or other bias. If localities want the potential to fine tune the QOF to their particular circumstances then I propose a bank of nationally agreed domains from which they could pick and choose. One might deliberately choose to have a rolling programme to encourage practices to assimilate new evidence, but without the tyranny of relentless, inevitable growth of the QOF. Des Spence refers to the patients as ‘unconsenting volunteers’, but does he give them the option to opt in, as well as opt out? He may find that even poor people in inner cities would like the chance to live longer healthier lives. Jessica Harris, GP, Oxfordshire Competing interests: GP QOF assessor for Oxfordshire PCT, and previously for Norfolk PCT |
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Des Spence, GP Maryhill Glasgow G20 9DR
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Did Streptomycin rid us of TB? Why did Rheumatic Fever die away? We need to be weary of Totalitarianism evidence on may different levels. Consider firstly our identified cardiovascular risk factors date back to what was measurable in the 1960s - there are possibilities many confounding unknowns. Secondarily, study populations are chosen because they are “at risk” ( interventions therefore have the highest chance of reaching significance) extrapolating results into general low risk populations is fraught with problems. The QOF assumes that widespread testing and treating risk factors would delivery evidence from studies to the whole population. We use the various formula to calculate those at risk and then treat. Nice Theory. But consider that Vascular Disease has been in decline over the last 3 decades (a gradient seemingly largely independent of statin use and our medical interventions ) So if the background absolute risk of cardiovascular disease declines then treatment benefits declines likewise. Also the CV risk formulas (other than ASSIGN) do not adjust for social class , add in the inverse care effect ( those of lowest risk most likely to receive intervention) - low risk populations are now being treated in the QOF. Therefore NNT double or triple compared to the original and decades old research . Thus the treatment paradox of the QOF is that swathes of the population are now “patients” but will never personally ever benefit. But even accepting that there might be a small benefit from the QOF - I would expect an intervention with the numbers and power of the QOF to have shown absolute benefit in death within 2-3 years from the research. ( consider the numbers in JUPITER study which was stopped prematurely after 2 years because of it highly significant effect ) So respectfully , I repeat my assertion – show me the evidence. Add other aspects of the QOF like Depression rating scores and obesity registers that have no evidence base – what are we doing? . Living longer isn’t the issue – living better is. We need to use our medical energies to advocate public health measures that will improve activity, diet and expectation. I don't mean to grumble. Competing interests: None declared |
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Andrew C Barnes, Civilian Medical Practitioner Germany
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I find myself in full agreement with the letter from Dr Spence, and nearly-full disagreement with the letter from Dr Harris. There are some QOF enthusiasts around, but my guess is that the vast majority of GPs are on Dr Spence’s side and are simply toeing the party line for a quiet life, and a little short-term profit. It is interesting to see that Dr Harris has received income as a QOF assessor, which surely compromises her own attitude on the subject. My perspective is coloured by overseas experience in several countries, and infrequent spells as a GP in the NHS, including when QOF was introduced.
I think that I can support Dr Spence best by directly questioning the assertions of Dr Harris: 1. “I was sad to read…” This implies an emotional aspect to QOF, which is not evidence-based but probably true considering my own temper. 2. “it seems so nihilistic and unimaginative”. My reading of Dr Spence’s letter is quite the opposite. Dr Harris’ statement is an insult, rather than a claim to intellectual superiority and invention. 3. “what prompted this in such an intelligent man?” This is a slur, actually meaning the opposite to what was said, and is more suitable to a Shakespearean play than a scientific journal. 4. “we really can have our cake and eat it” . I think that the real-life version is more accurate: “You can’t eat your cake and have it too”. 5. “British GPs are in the privileged position of being self-employed”. Has Dr Harris actually worked overseas? British doctors and patients are now being marionette-controlled by government to a perverse level, with the result that they have become purely reactive to the latest initiative from someone who does not understand patients and their messy lives. This is the greatest tragedy behind QOF. 6. “We can organise our lives as we see fit.” Is that what others think? From the patient registration system, to a million different rules, regulations, and protocols, there is scarcely room to breathe. Newly-qualified GPs are obliged to take salaried jobs because they are forbidden from opening up their own practice to compete in an established area. In Australia, I can put my name up in lights anywhere, at my own choosing. Now that is real freedom. 7. “We could use the extra QOF money to increase the length of our consultations”. More work, together with longer consultations? That means longer working hours. Given that the number of doctors is static over the short-term, what is the incentive in that? 8. This is astounding. I can barely get a sentence through this letter without needing to take issue with what is said: “Or we could share chronic disease management with nurses and health care assistants, much loved by patients, and less likely to baulk at following protocols and guidelines”. It seems that doctors baulk at guidelines more than their “much loved” nurses and HCAs. There could be an answer to that, and the simple version is called a medical degree and years of consultation experience. The complex answer is beyond the scope of this Rapid Response. 9. “QOF helps us implement evidence-based medicine”. This proves that Dr Harris does not understand the key point that Dr Spence is making. I have to say that the “helps us implement” part of that sentence is definitely not evidence-based, nor appreciative of the bigger picture. 10. “QOF actually liberates us from cluttering up our brains with the relatively easy bits of the job, giving us space for the more skilful, thoughtful aspects”. That is not my perspective. Much of the extra data collected is irrelevant to individual patient care and health promotion, and is distracting during consultation. Dr Harris is not taking into account the enormous effort and cost required to collect the data. 11. Locally-agreed QOF domains “must be based on robust clinical evidence, with no room for political, or other bias.” Who is she trying to fool? QOF was a political tool right from the start, and will remain so. 12. “…the tyranny of relentless, inevitable growth of the QOF.” At last, here is something I can fully agree with. Australian doctors saw the effect of the 1990 contract, and realised quickly that giving statistical information to politicians will have a negative impact on patient care, and defied requests for same. Information is power, and doctors in Britain should feel genuinely guilty for betraying their patients’ trust by providing every personal detail to government through the fiction of NPfIT. 13. “He may find that even poor people in inner cities would like the chance to live longer healthier lives.” Yet another non-evidence-based assertion. There is not a shred of evidence to suggest that the QOF system creates longer and healthier lives. Worse than that, it completely ignores the key determinants of same; lifestyle and socio-economic factors. Why can’t we state the obvious: It is not health-care provision that is the main determinant of long-term health; it is the day-to-day choices that our patients make for themselves that is the decisive factor. Collecting statistics on smoking prevalence and BMI will not change this at all. In Britain, the government consider that they ‘own’ health-care, and can demand what they want. It should surely be the patient who is in control of their own health-care options, with the public health perspective secondary. Then they might start to feel in the mood for making the ‘right’ choice. Competing interests: None declared |
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Charles Heatley, GP Birley Health Centre, 120 Birley Lane, Sheffield S12 3BP
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I'm a bit lost now folks. I cut my GP teeth up the road from Des Spence in Possil Park, Glasgow and am well aware that engagement with healthcare services is often well down the list of the average patient's priorities. At the time the contract was being negotiated, some form of performance indication had to be produced, and it had to be as close to evidence as possible to justify use of public money. If it had contained health improvement outcomes from the start, no-one would have accepted it as these would not have been achievable. If you provide a cervical cytology service in your practice, are you still buying into an older vehicle used to pay GPs to change behaviour? My suspicion is that as we get better at achieving QOF targets they will be made "harder" or start to reflect positive health outcomes. Doctors are supposed to be clever people so why not let them get on with playing this game whilst working out how to change they way they provide services that truly reflect the needs of their patients and populations. For my part I acknowledge that QOF is imperfect and try my best to do it in the background of the consultation. I too want to see much of the information gathering devolved from the GP consultation but also better understood by the patients who own it. Then I can ask, "How are you?" knowing I have time to listen to the answer. Mind you, I do think throwing money at the health service to "treat" the obesity epidemic is wasted. Perhaps I should become a public health physician, or even better a politician...hello, is anyone still reading this? Competing interests: Chair of executive, Hallam and South Consortium (a PBC consortium in SHeffield) |
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