Overzealous enforcement and pointless target chasing is harming patients, says Dr Clive Henderson
Let's get a few things straight. Some version of the QOF is a good thing to remove unwarranted variation in GP practice, and to promote evidence-based preventive medicine. But – and it's a big but – the QOF has created collateral damage, is overzealously applied and is injurious to the health and wellbeing of many.
Here's why. It costs lots of money and, given the finite nature of the NHS budget, starves resource for other elements of healthcare. Surely not, some would argue, given it stops serious events like heart attacks and strokes, thereby saving resource? No. It doesn't stop these events – it defers them. The same or equally expensive events happen later in life, with all the resultant health and social care costs. Perhaps many would have preferred a hip replacement along the way instead, to use their quota of resource for better effect for their quality-adjusted life years.
Along the way, many are damaged one way or another by medication to achieve these deferments in disease. Side-effects and the resulting iatrogenic hospital admissions are not rare. The efficacy of the drugs patients are encouraged to take every day are not always what they would expect. In the decision-making process, the ‘numbers needed to treat' are not usually explained.
Take statins. If initiated at 20% 10-year risk and there is a one-third reduction in cardiovascular events, this means over 93% of users are not going to have a tangible benefit from taking a drug every day for a decade. That statistic doesn't sound so good to a patient, does it?
So which patients should we target? Presumably those we have an evidence base for, and no others. In reality, hundreds of thousands of people in their 80s and upwards are being stuffed with polypharmacy with little evidence of benefit but increasingly of harm. The recent QOF mistake in reducing HbA1c to under 7% was particularly lamentable. Where is the evidence for tight glycaemic control for elderly patients? They are turning up in droves at A&E with falls and off legs (low blood pressure, hypoglycaemia, statin myopathy, confusional states and so on).
The wrong focus
While GPs are diverting their time to the doubling of consultation rates the QOF has brought, they are less able to cure the ill and more likely to admit or refer. They may also be breeding illness behaviour and depression, what with all the labelling of people as having a chronic condition and sorting out the worried well when blood tests come back with spurious but irrelevant variations from the normal range.
What about the whole dehumanisation of primary care that this target and template culture has engendered? The doctor-patient relationship, so precious to British GPs, is threatened by computer-gazing box-tickers. Even worse, we are required to do this in psychiatric consultations. The PHQ9 is an abomination surely introduced by a quango of academics with the interpersonal skills of a newt.
What about exception reporting? Well yes, if you don't want paying, are happy to risk interrogation by the QOF police and don't mind turning down an opportunity to get the wrong person to the right target.
The goalposts change so often too, with a lag before national templates are up and running. Patients are dragged out of work (another cost to society) to see the GP because last time we met I did not have the right box to tick. And thank you for the urine sample, but I have already recorded that you have microalbuminia 15 times. Let us hope lower leg hair loss is not introduced as a marker of peripheral vascular disease. Wanted: one healthcare assistant with excellent counting skills.
Dr Clive Henderson is a GP in Market Weighton, east Yorkshire