Intended for healthcare professionals

Editor's Choice

QOF and consent

BMJ 2010; 340 doi: (Published 17 June 2010) Cite this as: BMJ 2010;340:c3235
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    There’s no shortage of critics of the Quality and Outcomes Framework (QOF), by which general practitioners in England are paid more for meeting a range of performance targets. Six years after its launch, Steve Gillam now thinks it should be scrapped. In a head to head debate this week (doi:10.1136/bmj.c2710), he argues that the clinical improvements credited to QOF are in line with predicted secular trends, that “commercially constructed evidence” has pushed up prescribing rates, that pay for performance brings with it a “corrosive cynicism,” and that single disease based guidelines, implemented mainly by nurses, have eroded the deeper professional relationships that patients want.

    Niroshan Siriwardena acknowledges many of QOF’s flaws and agrees that the clinical benefits have been small. But he identifies other positive consequences: investment in staff, teamwork, and better organised, more reliable care. We should address the criticisms of QOF rather than throw away these gains, he says (doi:10.1136/bmj.c2794). Indicators with poor evidence should be dropped—the QOF for chronic kidney disease is at the top of Des Spence’s list (doi:10.1136/bmj.c3188)—and new ones piloted. “Despite the added administrative pressures, most GPs are endeavouring to provide holistic care by integrating vertical systems of disease management into horizontal coordinated care for their patients.” Do you agree?

    Nigel Hawkes doesn’t mention QOF among the skipful of labour government initiatives to be “disempowered” by the new health secretary Andrew Lansley (doi:10.1136/bmj.c3128). But he makes it clear that GPs are in for a hectic time. The reforms will propel them into centre stage whether they like it or not. “Do GPs really want to commission 95% of NHS care? Have they the capacity?” he asks. And what role then for the soon to be democratically elected primary care trusts? With a new independent NHS board and an end to strategic health authorities, this could be, he says, the biggest change in a generation. “Mr Lansley is gambling that better informed patients and reinvigorated professionals can do more than central targets and bullying managers to improve the quality of the NHS.” We must hope that his gamble pays off.

    Elsewhere in this week’s journal, Susan Bewley and colleagues are rightly critical of the American Academy of Pediatrics for its recent intervention on female genital mutilation (doi:10.1136/bmj.c2728). The AAP suggested that US law should allow doctors to “nick” young girls’ genitalia as a cultural compromise to minimise harm. But, say our authors, the debate has moved on from harm minimisation to harm eradication, with a clear focus on the child’s best interests and their inability to give consent. “A girl without a problem is not a patient,” they write.

    What of people on death row? Should doctors be involved in their execution? In an article last month Mike Weaver argued that they shouldn’t. “There is no patient, harm is done on purpose; and there is no consent. So, no health professionals belong here” (BMJ 2010;340: c2643, doi:10.1136/bmj.c2643). But in this week’s letters Michael Rivlin asks, (doi:10.1136/bmj.c2980) “What if the subject does give consent or even implores the doctor to make the death as painless as possible?”


    Cite this as: BMJ 2010;340:c3235


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