Blanket treatment of the over-75s goes against what we were taught at medical school and has left us with a proliferation of drug-induced side-effects, says Dr Tim Cantor
The QOF element of the nGMS contract heavily borrowed from a scheme that was pioneered in East Kent called PRICCE (Primary Care Clinical Effectiveness). The inventors of PRICCE wisely took an ageist approach, excluding patients aged 75 and over from the process.
When the QOF started in 2004, the only major difference between it and PRICCE was that there was no upper age limit. It would have been unthinkable for the politically correct Labour government to have excluded over-75s from the QOF – it would have been accused of treating the elderly as second-class citizens.
It is now quite difficult for anyone to reach their 80th birthday without being on an antiplatelet or anticoagulant drug, a statin, an ACE inhibitor and a proton-pump inhibitor.
At medical school, we were taught to try to avoid polypharmacy in the elderly as they are more susceptible to side-effects and drug interactions. Thanks to the QOF, that approach has largely been thrown out of the window. Instead we have a generation of old folk suffering from a variety of drug-induced side-effects such as pruritis, anorexia, nausea, dyspepsia, heartburn, dizziness, diarrhoea and myalgia.
Nobody seems to have bothered to ask the elderly whether this is what they want. My impression, after 37 years of medical practice, is that most elderly people do not want to live to be 100. What they do want is good quality of life for whatever time they have left.
Furthermore, the evidence on which the QOF is based needs to be taken with a hefty pinch of salt. Some of it involves research on younger age groups that may not be applicable to the elderly. Many elderly patients with multiple pathology that GPs see would be excluded from clinical trials because they have too many confounding factors.
The addition of chronic kidney disease to the QOF has made a bad situation worse, as far as many elderly patients are concerned. Many of us used to consider a mild degree of chronic renal failure to be a normal part of the ageing process. Not any more. Now it has to be treated as yet another disease.
Heart failure is another problem area. I have yet to meet an elderly person who says he or she feels better for being put on a ß-blocker for heart failure.
I am not arguing that all patients aged 75 and over should be denied access to antiplatelet drugs, statins and so on. But the problem with human beings is that we do not all age at the same rate. Some 80-year-olds may be enjoying busy, active lives, whereas others may be demented and severely disabled. We need doctors who are prepared to use their clinical judgment in deciding whether a particular intervention is in the individual patient’s best interests.
Inevitably, this involves an element of playing God, about which some doctors may have misgivings. However, in most cases, GPs are probably better placed than anyone else to make such judgments, as they have in-depth knowledge both of the patient and the medical issues involved. The removal of the over-75s from some QOF domains would help us in this difficult task.
Dr Tim Cantor is a GP in West Malling, Kent
Dr Tim Cantor