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New hypertension targets in the QOF will create a wave of dissent

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The latest incarnation of the Quality and Outcomes Framework has recently been announced, inevitably bringing with it tighter targets and new treatment requirements.

One of the most eye-catching changes is the new instruction to prescribe statins to patients with hypertension. As of 1 April, all patients with a calculated 10-year risk of heart disease or stroke of 20% or more are to be prescribed the lipid-busting drugs.

I noticed this particular dictat with interest, since it reminded me of an impromptu experiment I recently conducted with a group of final year GP trainees. I asked the trainees to consider whether or not they would personally consider taking a statin; more specifically, what level of number needed to treat (NNT) would they require in order to reduce their risk of heart disease or stroke, before they would consider starting treatment.

We created an imaginary line in the middle of the room, with an NNT of 1 at one end, and 100 at the other. The trainees were then asked to stand along the line at the position that would be in keeping with their views about their own health. 

If we assume that taking a statin will result in a 25% relative risk reduction over 10 years, then a 20% CVD risk will be reduced by 5%, giving a number needed to treat of 20. Of the 20 trainees in the room, four stood on the treatment side of this line, while the other 16 all felt that they would only take treatment for a NNT less than 20 - with several wanting an NNT of less than 10 before they would consider taking the statin.

In other words, 80% of the trainees in my quasi-scientific experiment would not want to comply with the new QOF target if they were the patient - despite the fact that most of them would have no qualms about recommending treatment at this level to their patients.

I am increasingly struck by the language we use when patients dare to differ. If they don’t want to take the medicine we have prescribed, we describe them as ‘non-compliant’ - implying that the patient should always comply, like putty that should mould with the will of the doctor. If a woman does not accept her invitation to cervical screening she is described as a ‘non-responder’, with no acknowledgment that she may not have wanted the invitation in the first place.

As for the QOF, the patient has two options outside the realm of orthodoxy - options that come under the label ‘exception reporting’, where the GP has to explain why this particular patient has not hit the target.

The first is to be deemed ‘unsuitable’. (Note that it is the patient who is unsuitable for our blameless treatment, not the other way around, as though they are in some way defective or unworthy to receive the benefits that could otherwise be bestowed upon them). The alternative is for the patient to exercise ‘informed dissent.’ Dissent? Have we thought about that word?

The popular narrative at the moment is for patient choice, but when it comes to decisions about their own treatment, patients are not permitted to choose - they have to dissent. Dissention is not simple disagreement; it has religious overtones, rejection of the accepted norm, heresy even. It implies an awkward patient, and can appear like a black mark on their record. What is more, it has overtones for the doctor as well. It may be reasonable for 50% of your patients to make a particular choice, but how many could possibly want to dissent?

If we are really to put patients - and not doctors, medical experts, or the Government - at the centre of healthcare, then we must change the way we label their choices. We should describe treatments as unsuitable, not patients; we need to allow patients to exercise informed choice, and free them from the outdated, hierarchical model that considers ‘informed dissent’ to be appropriate terminology.

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.

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