Those QOF alerts can wreck the flow of the consultation. They’ve become even more important now of course, with higher benchmarks and less money.
A thirty-something comes in to see me for her annual Pill check. She’s had the pill for over ten years now. She takes it appropriately, has regular periods and has told countless colleagues that no, she is not interested in long-acting reversible contraceptives (LARC).
Yet still, it’s there on-screen in toxic red. I can’t ignore it: LARC ADVICE, LARC ADVICE.
She sails through the Pill check, we exchange pleasantries. I could just let her go and then code that I gave LARC advice. I can’t do it – out it comes: ‘Now tell me, have you thought about the coil, or the implant perhaps?’ It was half-hearted at best. ‘No, I like my Pill, thanks, and have done for years.’ Exit slightly disgruntled patient.
The next patient is a 74-year-old, an unfeasibly spherical diabetic with an eye-watering BMI of 46. He takes his metformin like Rennies.
He has a dozen QOF alerts blaring at me. I tick them off one-by-one, bouncing between his agenda (fungal nail infection) and mine (QOF, QOF, QOF). The screen shouts, LIFESTYLE ADVICE, LIFESTLE ADVICE.
I just can’t broach it. Come on, he’s been to diabetic clinic recently, surely the nurse told him to join a gym? But I can’t resist. ‘Have you considered grilling or roasting your food?,’ I ask. No, he says, it gets delivered most nights and I get a free poppadum. He leaves, feeling annoyed.
My third patient is only 16, and she’s come with her mum. She had a sore throat, Centor score of 4 and a patient-centred justification for 10 days of penicillin V. Marvellous.
But there it is though, brighter and redder than her uvula: OFFER CHLAMYDIA SCREEN. GO ON, OFFER THE YOUNGSTER A CHLAMYDIA SCREEN. This one’s not for QOF but it still earns us a fiver.
She’s got her coat on, Mum grabs her bag. I can’t hold back, we need the money. ‘Before you go… Would you like a free chlamydia screen on the NHS?’
Then, in an inaudible mumble: ‘They’re offering them to all 16-24 year olds. ‘
The patient goes bright red, her mum looks aghast. She’s not the sort of girl you’re after, says Mum firmly. And they leave highly annoyed.
I realise the importance of QOF: it focuses minds, keeps the chronically diseased in check, bolsters the flagging finances. But the great skill (and one I have yet to master) is managing its seamless incorporation into the consultation.
There are ways round it. in the first consultation, I could have asked the patient if, having been on the Pill for so long, she wouldn’t want a Depo?
Or joked to the diabetic patient: ‘Your BMI’s hit 48 – maybe it’s time for a salad, haha!’
To the teenager: ‘You have a bacterial infection in your throat… Shall we check you haven’t one elsewhere? ‘
They don’t test this in the CSA, but perhaps they should. I would certainly have failed with the next patient: ‘Mrs Smith, I believe you’re overdue for a smear?’
‘Not likely lad, I had a hysterectomy in 1983.’
Tom Gillham is a GP in Hertfordshire and Specialty Doctor in A&E. You can follow him @tjgillham.