Intended for healthcare professionals

Rapid response to:


Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study

BMJ 2009; 338 doi: (Published 27 May 2009) Cite this as: BMJ 2009;338:b1870

Rapid Response:

Qof provided equity for patients

Dr Calvert et al are to be congratulated on this major analysis of
Qof in relationshop to Diabetes.
There is no doubt that the READ codes caused a headache for all practices
and this is not the fault of Qof but of the technicians who implemented
it. It can be sorted.

I did my first diabetic audit in my British general practice in 1982
and my last one in 2006 when I retired. There is no doubt that all
parameters that we measured improved over time. However what will not be
seen by large analyses is the behaviour of different doctors in a
practice. By the end of the nineties half of my partners were embracing
the findings of UKPDS and other trials and improving their management of
their diabetics. However the other half were reluctant to change hanging
on to a outmoded concept of 'professional independence' and treating
'everyone as an individual'.

When Qof was offered the therapeutic decisons about cholesterol and
blood pressure were now embraced by all doctors and at last the greatest
cause of inequality of health care in our practice was not the doctor you
were registerd with.

Alongside this we had been training our practice nurses in diabetic
care over many years and when qof was introduced they were well placed to
take over much of the routine followup with much greater attention to
detail than the doctors.

Qof did not suddenly change the way our practice worked but it did
provide some reward for the heavy financial investment we had made in
education and employment. More fundamentally it made more reluctant
doctors embrace newer tretments and aim for better outcomes.

In the hurly burly of practice the last thing on my mind was whether
we had acheived a ceiling. We strove to give as good a care as possible to
all our diabetics whether on a register or not. That the hospital failed
to supply us with a considerable amount of data about the type 1 diabetics
they were supposedly looking after was a continual source of aggravation.

In my last audit I looked at those with HbAic over 10 and found the
majority were patients who we had sought to influence but were failing.
Several needed insulin and were adamant that they were not going to take
it and others were poor attenders, had alcohol problems and chaotic
lifestyles. All had been several times to our clinic but we had not be
succesful in changing their behaviour.

Qof revolutionsed the care that our patients received, ironed out
inconsistencies within the practice and will be of lasting benefit to the
patients. The doctors still have professional independence and can look
after each patient as an individual but at least the patients are
receiving appropriate therapy.

Competing interests:
None declared

Competing interests: No competing interests

08 June 2009
Rupert A Gude
VSO Doctor
Kagondo Hospital, Kagera, Tanzania