hoolet issue 44 

Spring 2005

Chris Johnstone Intro.
Cons in the consulting room...
Right to Die for the Terminally Ill Bill
The Alasdair Short Travelling Fellowship
Disintegrating Care - or The Vale of Tears
The Watching
Nofreelunch Needs You!
Hoolet Christmas Competition
0870 to 0844
Reverie in a Sauna
NHS plc -The Privatisation of Our Health Care...
A Cat in the Bag
Changing Times
Time to go Killorglin
The Pendleton Code
Hoolet Exclusive

That's a Nasty QOF

By Chris Johnstone
Contact the editor by e-mail at christopher.johnstone@ntlworld.com

I am writing this in early March. We are in the final straight of the first year of the new contract and the QOF specifically. Being only marginally obsessive I only check our points score on a daily rather than hourly basis. I don’t trust QMAS and I am sorely irritated that it only appears to update on a monthly basis. How can a paid up member of OCD Anon survive?

You are reading this in early April. D Day has passed. Everything has gone swimmingly or else there is universal chaos. I hope isn’t the latter. I enjoy a disaster as much as anyone else, but there have been so many setbacks, hassles and scares in the past few months, that all I want is a straightforward calculation of our achievements and an equally rapid payment. Well, it doesn’t hurt to dream.

For the past year we’ve all been running around, chasing our patient’s tails and totting up them ol’ points. Initially there was funding for 90% of GPs to attain 900 points. After some political/financial tinkering with the MPIG, this was reduced to 80% attaining 800 points. Both estimates seem fairly way off the mark with many practices aiming for over 1000 points. As one of our local managers said, successive governments have always underestimated GPs resourcefulness where money is involved. Anyone remember our enthusiasm for health promotion clinics?

In the heat of the chase it is easy to forget why we are doing this. As we double the statin of our elderly CHD patients to drop their 5.01 chol below the magic 5, the lure of money making points can obscure the real purpose of the Quality and Outcome Framework. There has been a public health revolution in the past twelve months. We have been heartily incentivised to implement some serious evidence-based medicine. Reducing blood pressure, HbA1c and cholesterol, prescribing aspirin, beta-blockers and ACE inhibitors makes a difference. Theoretically the health of patients with the most common chronic diseases has taken a step change in the past year. In our practice we thought we were pretty good at looking after patients with diabetes, hypertension, asthma and CHD. But when we ran our first audits we discovered we were not quite as wonderful as we thought. I can tell you that we are a hell of a lot better now (and I hope QMAS can as well).

If the evidence is right, there will be a lot less admissions, deaths and complications in the coming months and years. If the evidence is right, implementing the QOF will lead to a happier, healthier UK with a lot less pressure on secondary care and less time lost from work. If the evidence is right.

I have embraced the point chasing QOF as much as the next GP, but my fear is that for all the time and effort we put in, the medical rewards will be slender. You have to treat hundreds of patients for years to prevent a further MI. The NNT for most interventions are in the hundreds. Small and medium sized practices will not see any difference in the health of their populations, despite massive amounts of time and effort spent on going from 85% to 91%. The cost is going to be spectacular in payments to GPs and to their staff, our postage costs alone have risen 800% and we are employing more nurses. Prescribing costs have soared, with the most expensive drugs having the least effect, aspirin has a much better NNT than statins.

And the effect on patients is not negligible. Many are happy to be invited for health checks, but start to get irritated at the number of times they have to return for blood checks while their cholesterol stubbornly hangs around 5.2 and the number of medicines they are taking quadruples (especially if they pay for their prescriptions). I find myself staring at the computer much more during consultations. Patients find it disconcerting that while they are telling me how miserable was their childhood, all I am interested in is whether they have stopped smoking yet. Maybe it is right I should concentrate more on their slightly raised blood pressure than their problems with their boss, but the nature of the consultations has altered slightly. It is less personal, more mechanistic. EBM and public health are winning, we are becoming less interested in the individual and more the guardians and implementers of public health policy, whether it is right for that individual patient or not.

For those of you who were unaware, it with great sadness that I report Somerled Fergusson’s passing. Somerled was a good friend to hoolet. His series of articles, Tales of a Grandfather, embodied all that is good about Scottish general practice and helped form hoolet’s distinctive voice. We will run a full tribute in the next issue. In the meantime our condolences go to his wife and family. We will not see his like again.

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