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Box-ticking misses trick

The quality framework has always provoked a mixed reaction among GPs, with as many bemoaning its impact on continuity of care as lauding its potential to improve clinical outcomes.

There was broad buy-in to the first set of indicators, with few arguing over the benefits of controlling blood pressure and cholesterol. But that changed with the first set of revisions, with GPs particularly irritated by the new requirements for formal depression screening and assessment.

An evaluation this week shows exactly why GPs were so sceptical. It turns out the controversial PHQ-9 questionnaire, which most are now using to classify their depressed patients, is rather less reliable than GPs had been led to believe. Far from improving the evaluation of depression, it is systematically overestimating severity and putting thousands of patients on medication they don't need.

The most frustrating thing about these findings is how predictable they were. Yes, assessment by human beings is messy and subjective, but it is also warm and intelligent and flexible. GPs are capable of making subtle judgments based on the needs of individual patients, whereas questionnaires are capable only of crude calculation, reducing patients to positions on a chart.

With two further studies this week questioning the impact of the QOF on quality of care, doctors need to ask how much they are prepared to see the art of clinical practice engulfed by the false science of tick-box medicine.

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