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QOF led to over-medicalisation, Scottish CMO says

The QOF and the widespread use of evidence-based guidelines has led to some patients with multiple long-term conditions being given far more medication than is beneficial, Scotland’s chief medical officer has said.

Dr Catherine Calderwood argues that the guidelines were developed for people with single diseases but have been applied to those with multiple illnesses, resulting in a ‘massively increasing volume of medication’.

In her annual report for 2014/15, Dr Calderwood said this has heightened the risk of side-effects, falls, confusion and hospital admission.

The QOF is being scrapped in parts of Scotland in April as part of a new GP contract.

Dr Calderwood’s report states: ‘Since 2004 the GP contract has introduced a quality and outcomes framework, incentivised by performance-related pay, encouraging doctors to use evidence-based guidelines, mostly developed for people with single diseases, to treat patients who very often have multiple conditions.

’The widespread use of guidelines has contributed to the massively increasing volume of medication taken by the population each year… With the increasing complexity of multiple drug regimes come the inevitable loss of uptake, increased potential for interactions and side-effects, and a significant increase in the risk of unintended harm, such as falls, confusion and hospital admission.’

She adds that doctors ’tend to underestimate the frequency and impact of side-effects from treatment and fail to understand the total treatment burden that may be forced upon patients’.

Because of this, she argues: ’It will be in the better interests of patients to have intelligent, patient-centred use of evidence-based guidelines, a reduction of over-literal interpretation of evidence, and support for doctors who provide a skilled and generalist view using their clinical judgement to advise patients and then make shared decisions of realistic goals and treatment options.’

BMA Scotland argues that doctors’ low morale and their heavy workload could affect their ability to make the necessary changes.

Council chair Dr Peter Bennie said: ‘While doctors can play a vital part in supporting the development of new approaches to healthcare models, we must recognise that morale among Scotland’s doctors is very low with workload intensity continuing to rise, and that this is likely to have an effect on how well doctors can respond.’

Montrose-based GP Dr Graham Kramer, the national lead for self-management and health literacy, was a co-author of the report.

Readers' comments (8)

  • how refreshing to hear a senior administrator say some common sense statements

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  • QoF at its outset was a good idea but it was simply used by DoH and NHSE as the penance and stick to beat general practice with.

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  • Antidepressants have led to over medicalisation

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  • Over diagnosis, over investigation and over treatment are common scenarios

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  • The thing is that they are many people you over treat because QOF is public and if you do not treat someone your percentage falls and you are seen as a bad doctor.

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  • The article states 'morale among Scotland’s doctors is very low with workload intensity continuing to rise, and that this is likely to have an effect on how well doctors can respond.’ The question is - how much of their workload is due to the overprescription of drugs, adverse side effects of what they are prescribing and interactions between medications?? a vicious circle turning into a downward spiral?

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  • Can someone offer Dr Calderwood a job in England? QOF was good for the first 2 years, however good medical practice & common sense were not allowed to prevail with patient medication. Giving out excess hypertensive & lipid lower medication has particularly irked me. I have seen my fair share of drug inter-reactions. All this extra QOF activity generated huge amounts of extra work & has finished off many doctors. I now work part time, which has been a blessing & kept my sanity.

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  • We must be very careful of the next step. DH will use this evidence to remove funding from general practice, or at least to offer us the same funding to do something extra (7 day working). What should happen is that the QOF money goes straight into the global sum to support the healthcare teams that we have developed as a result of QOF.

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