For every new QOF there should be a QIF
Copperfield lambasts the additional workload that the 2026/27 contract’s new QOF requirements will dump onto GPs
Among the many jaw-droppers in the new contract was the QOF requirement to follow the four-pillar faith of cardiac failure treatment. I realise we’re supposed to be fanatical about this cardiological doctrine and I’m completely sure that the evidence base behind it is 100% applicable to the polymorbid, multi-medicated and hyper-dysfunctional masses that constitute our real-world patient lists.
But it does beg some maths. Sequentially initiating and titrating all those drugs comprises about 16 separate appointments and at least five blood tests. Work it out yourself if you don’t believe me. Taking account of lab interpretations, the odd blip and the inevitable patient or pharmacist queries, that’s, let’s see, about 25 clinical interactions per patient. For 12 reallocated points.
I feel a bit sorry for the uber-medicalised patients but, hell, we’re saving their lives, right? So, I feel most sorry for us GPs, whose lives are being ground down.
Of course, we could just bung each patient on all four drugs from the get-go. But that way uninterpretable side effects, AKI and madness all lie.
Or we could bounce them all to the Community Cardiac Failure Team. To which you might reasonably reply: What Community Cardiac Failure Team? Or, do you mean the Community Cardiac Failure Team that has a one-year waiting list because, for QOF purposes, everyone is sending their cardiac failure patients to the Community Cardiac Failure Team?
In short, this is an impossible quantity of work. And, of course, it’s just one of many I could pluck from the new contract, such as the doubling down on online access or the new horrors of A&G. In a sane, just and reasonable world, we’d be able to cite opportunity cost and insist that workload gear shifts like this should mandate a ‘Quantity Interruption Framework’ – or QIF – telling us what work to stop.
But our world is insane, unjust and unreasonable, so there is no QIF. And the latest contract just reiterates what we have always known. Which is that politicians believe GPs can forever expand their remit, because they reckon we were doing sod all before.
Dr Tony Copperfield is a GP in Essex
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READERS' COMMENTS [9]
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A nasty QOF? Try VICKS™ – senior partners swear by it (Very Inappropriate Cheating as a Key Strategy 😉)
Completely agree. Add to this that the number of available QOF points has remained static over the past 10 years, the value of a QOF point has dropped relative to CPI, that patient numbers have increased by approx 25-30%, and prevalence of disease (and the workload associated with treating it) has also gone up. This means effective payment per head has dropped quite considerably.
The new CQC inspection searches also mean that you are still expected to perform the ‘retired’ QOF indicators as well as the new ones.
It isn’t just the GMS contract that needs a total redesign.
At my 30,000 patient practice we have real world evidence that starting the 4 pillars has reduced symptom burden – both NYHA score and severity of oedema. the results are good, but I totally agree that this represents a huge burden of work that I doubt will be funded appropriately because its a hell of a lot of clinical interactions!
You mean the community heart failure team that says “Yes, Mrs X has heart failure, please initiate and titrate them up according to the four pillars of treatment, and arrange repeat echo in 6 months. Follow-up in never years.”
Community heart failure team is absolute epitomy of rising to their level of incompetence. I’m glad that there is a career destination for band 5 nurses from the cardiology ward but cmon, where is the job satisfaction in asking GPs to check daily pulses and U&Es in a patient you’ve requested we start on 1.25mg of bisoprolol and 1.25mg of ramipril
While the frustrations expressed in the article are entirely valid, we must also be honest about the fundamental tension at the heart of modern general practice: we are expected to deliver gold‑standard, evidence‑based medicine in an environment where the resources, workforce, and capacity simply do not exist to meet those demands.
1. Evidence‑based medicine must operate within the limits of real-world capacity
No clinician disagrees with using the best evidence available. The issue is that evidence‑based pathways were developed in controlled environments with tightly defined patient cohorts—not the multimorbid, socially complex, frail, and polypharmacy‑laden reality of UK general practice.
If a QOF requirement expects 16+ titration appointments and at least five blood tests per patient, we have a duty to point out that this does not scale across lists of thousands. Evidence‑based care is only meaningful if it is deliverable. Otherwise, it becomes an exercise in policy fiction rather than clinical reality.
2. False expectations are being set by government messaging
Successive governments have repeatedly raised public expectations—“same‑day access”, “online access expansion”, “more appointments”, “faster diagnostics”—while simultaneously reducing per‑patient funding in real terms and eroding GP workforce numbers.
When expectations are raised without the funding to meet them, the public interpret system failure as a GP failure. But this mismatch is not created by clinicians; it is created by policymakers.
3. Transparency with patients is not unprofessional—it is honest
We should absolutely remain compassionate and patient‑centred, but being honest about system constraints is part of that duty.
If voters are repeatedly promised impossible standards of care while the system is being defunded, we cannot be expected to silently absorb the consequences.
Patients deserve the truth about why access feels harder, why waiting lists are longer, and why their GP is stretched to the limit. That truth is not “GPs are doing nothing.” It is that resource has been cut while demand has risen beyond any reasonable limit.
4. Ultimately, voters influence the government that shapes the NHS
It is not about blaming individual patients—it is about acknowledging collective accountability.
If the electorate votes for parties that reduce funding, expand contractual burdens, or pursue policies that hollow out primary care, then inevitably the service they receive will reflect those choices.
Just as we must own our clinical decisions, society must own its political ones.
5. Without a QIF, the system incentivises unsafe, unrealistic expansion
The author is right to point out that there is no “Quantity Interruption Framework”—no mechanism to stop existing work when new demands are added.
But rather than simply lamenting this, we should assert clearly:
High‑quality medicine requires prioritisation, and prioritisation requires honesty about what can no longer be done.
Otherwise, we invite burnout, unsafe practice, and deterioration of care quality.
VICKS™: Very Inappropriate Cheating as a Key Strategy
A long‑standing, unofficial survival technique whispered in GP partners’ meetings up and down the country—usually after QOF updates, DES launches, and contract “uplifts” that uplift nothing except blood pressure.
Below is an expanded, playful interpretation you can use:
1. The Origins of VICKS™
VICKS™ allegedly began in the late 2000s when senior partners realised that every year brought a new wave of politically‑motivated targets, bureaucratic contortions, and magical-thinking expectations that bore no resemblance to reality.
To cope, a coping strategy was born. A deeply inappropriate, entirely unofficial, but weirdly effective philosophy:
If the system demands the impossible, the only logical response is to survive it creatively.
2. Core Principles of VICKS™
Think of these as the “four pillars” of the alternative chronic GP management framework:
a) Prioritise What Actually Helps Patients™
Not every box needs ticking. Not every metric deserves worship.
VICKS™ senior partners are masters at spotting which targets are clinically meaningful and which exist purely to satisfy someone at NHS England who once read a Harvard Business Review article on KPIs.
b) Challenge the Fantasy™
When QOF assumes a CHF titration schedule that would require an extra 2 GPs per 1,000 patients, VICKS™ doctrine says:
“Do what’s safe, what’s evidence‑based, and what’s actually possible—not what looks good in a ministerial press release.”
c) Document the Madness™
A core VICKS™ lesson: never let the system gaslight you.
If you are expected to deliver specialist‑clinic‑level longitudinal medication optimisation with no staff, no appointments, and no time—record the constraints.
Because transparency isn’t just protection; it’s honesty.
d) Educate the Public™
VICKS™ orthodoxy holds that patients cannot be left believing the propaganda that “GPs aren’t doing enough.”
Senior partners encourage gentle but frank conversations with patients:
“Yes, this is the gold‑standard pathway.
No, the government has not funded the staff or infrastructure to deliver it at scale.
If you are frustrated, you should be—please raise it with your MP.”
This isn’t political—it’s factual accountability.
3. Advanced VICKS™ Techniques
Veteran partners practice these with near-mystical precision:
The Tactical Referral:
When overloaded teams are meant to absorb new QOF burdens, VICKS™ says:
Share the absurdity with secondary care.
The Opportunistic QIF:
Since NHS England won’t create a Quantity Interruption Framework, VICKS™ practitioners create their own by quietly deprioritising low‑value work to protect safety and sanity.
The Strategic “We Will Add to the Waiting List”:
An elegant manoeuvre signalling:
We recognise your guideline.
We respect your evidence.
And we will deliver it… when capacity materialises, sometime around 2043.
4. The Philosophical Heart of VICKS™
At its core, VICKS™ is not about cheating patients.
It is about cheating a system that is cheating patients by:
promising more than it funds
setting standards it cannot meet
pretending GP capacity is infinite
blaming clinicians when reality intrudes
VICKS™ is survival humour—born from the mismatch between political fantasy and clinical reality.
5. Why Senior Partners “Swear By It”
Because without humour and a touch of rebellion, the system would grind everyone down completely.
VICKS™ is a way to stay human in an increasingly inhuman structure.
It is satire—but sharply accurate satire—of the strategies GPs must adopt simply to keep going.
Like your posts, Dilar, and your working of VICKS into a “General Theory of Engaging NHSE” 😂
NHSE bureaucracy, long ago now, divided up holistic GP care, manufactured clinical targets/QOF and incentivised them, believing that ONLY economic forces motivated GPs in practising their unique traditional Care. They demoted the moral and emotional imperative that is encoded in the DNA of GPs, and irrevocably changed the parameters of the GP-patient relationship. The pen-pushers had to kill “the goose that laid the golden egg”. And, though QOF has brought benefits, we’ve also ended up with harms and unintended consequences, eg, perverse incentives, or treating to QOF rather than treating the whole-patient, etc.
Narrow-thinking economists assume that monetary incentives always improve performance, yet extensive psychosocial research undermines their claim.
See “Hanoi rat-catchers 1902”, “the cobra effect”, “Israel late pickup day care centre” etc.
Keep the QOF evidence-base for GP support, rather than for mass monitoring/nannying, get rid of the incentive/target paradigm, and put QOF monies into Global Sum.
How can I vote for Diler Ahmed?