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: Re: Re: Ethics of QOF

Dear Edward,

I do understand your concern that cash incentives might encourage
doctors to do the wrong thing. It depends on the thing incentivised,
since GPs definitely respond to money. Even in direct cash-transactions
between patient and private doctor, or third-party (eg. drug or insurance
company) and doctor this danger exists. Hence we have professional
standards and scrutiny overseen by GMC and courts. I can be struck off if
I behave unethically. Thankfully I can quote the Bolam defence ( most of
my reasonable colleagues act similarly ) in regards to QOF.

Are you against all cash incentivisation ?

In the real world doctors are paid to perform to the State ( NHS )
expectation, and very few doctors work for purely altruistic motive.. I
employ £100,000 worth more healthcare professionals through QOF, and I
would not do it if I thought it unethical. What form of performance-
related payment would you agree to ? Personally I am content that we have
a sufficiently pluralistic open and voluntarily-negotiated process by
which evidence-based QOF measures are agreed, and constantly argued over
by all parties. Long before nGMS I was paid a fee per vaccination, or
night visit, etc. from the National Tariff. Then came percentage
threshold targets, by which I was only paid if 90% of eligible children
had MMR vaccination. I believed MMR was safe and effective. But if three
of my patients refused the jab, I would lose £3000. Was that ethical ? It
was certainly salutary.

I too believe that an HbA1c target of 6.0 or 6.5 should not be
incorporated. But do you agree that a higher HbA1c target is sufficiently
evidence-based ? Would any target be acceptable for cash incentive ?
Should doctors be paid at all ?

QOF can be very tedious, and a tiresome tick-box exercise for many a
diagnostician ( hence most GPs delegate it to dedicated Nurses) - but
evidence shows it has encouraged better chronic disease management, more
equitably across the land, with many more BPs, and Cholesterols downward,
much to Mark's chagrin. If our DoH paymasters didn't get the results they
want, you can be sure they would quickly withdraw the point/pound. It
came is shock to the NHS managers to find most GPs hitting nearer 100%
targets, and they have been trying to claw back for the last 3 years.
Heaven knows what recession will bring.

I shall probably retire, or leave the country.

Competing interests:
I accept payment as an NHS GP, including QOF

Competing interests: No competing interests

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