Intended for healthcare professionals


Tight control of blood glucose in long standing type 2 diabetes

BMJ 2009; 338 doi: (Published 06 March 2009) Cite this as: BMJ 2009;338:b800

Re: Re: Re: Ethics of QOF

I do apologise to Mark for seeming patronising. I wished to be
factual and reassuring.

I did wish to express the perfectly valid view, held by most GPs (
they voted for it ), and negotiated by our elected representatives, that
the Quality Performance-related payment scheme ( QOF ) is indeed
voluntary, and if we GPs wished so we can opt out either collectively or

Taking Mark's points in turn:-

"I am alarmed that Dr Lewis can write so patronisingly towards a
student colleague. I believe Edward Chandy’s alarm is very far from
misplaced. To say that QOF is worth a substantial proportion of practice
income on the one hand and also say that QOF is voluntary and that no
doctor is forced to participate is being slippery to say the least. Please
consider the junior partner or the salaried GP and the pressure to conform
to QOF for the financial health of a practice."

I did mention my nurses, and my partners - who would not be on our
payroll but for QOF. I think the work they do is first-class, evidence-
based, and of high value to our patients, else I wouldn't employ them fro
this purpose.

"The proposed new targets in diabetes are a potential source of

Our negotiators agree the evidence-based targets, and soon NICE will
add it's opinion. If the GP feels that the target is not indicated for
any individual patient then he can except them.

" As another example of conflict, consider coronary heart disease
(CHD) and the controversial cholesterol hypothesis: some doctors believe
that the relationship between the cholesterol level and the development of
CHD is tenuous and that artificially lowering the level may actually be

Those doctors need merely to except women from the targets.

" A paper published in the BMJ (2007) revealed that in women at
least, there was no mortality benefit in taking cholesterol lowering
drugs, despite their enormous cost and morbidity inducing potential."

This is a selective reading of the evidence.

4S showed categorically that post-MI patients had a 20% mortality
reduction, and a 30% heart attack reduction.

HPS showed categorically that Diabetics ( aged over 40) benefitted
similarly (in relative terms ).

" And yet the QOF incentivises the measurement of cholesterol and the
cholesterol lowering achievements of the practice. In effect the QOF
coerces some doctors to measure cholesterols and prescribe the statin
drugs against their evidence-backed judgement."

I do agree with Mark that sub-group analysis ( a questionable
practice) of low-risk patients ( eg.women ) does not show mortality
benefit. It is entirely scientifically possible that women are indeed
unable to benefit from Statin. I discuss the evidence with my female
patients , and we reach an informed decision, which thankfully is not
penalised under QOF. Indeed QOF restricts its cholesterol targetting to
only those patinets who have CHD, Stroke , or Diabetes. In my own reading
of the evidence, I am in full agreement with NICE, and look forward to the
inclusion of HIGH CVD RISK patients in the cholesterol-targetted cohorts.
This would not include many women.

I agree that Edward had every right to raise his concerns, and I
would encourage him to engage further in honest, rational, evidence-based
discussions. Disagreement is not uncommon amongst doctors, and is often
very healthy. Evidence often has more than one interpretation, and GPs
usually have several conflicting values.

Competing interests:

Competing interests: No competing interests

21 April 2009
L Sam Lewis
GP Trainer
Surgery, Newport, Pembrokeshire, SA42 0TJ