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9 October 2017

At last, we seem to be awakening from the bad dream of “tick-box medicine”

Doctors allowed themselves to be reduced to automatons.

By Phil Whitaker

The Quality and Outcomes Framework (QOF) makes up a sizeable chunk of a GP’s income. At its launch in 2004, QOF was presented as a major advance – a system for financially rewarding those doctors who provide the best care, which would in turn incentivise less adept colleagues to up their game.

It was billed as the largest payment-by-performance scheme in the world, and patients, we were told, would inevitably benefit. Looked at from this vantage, however, QOF represented the beginning of a disastrous era in medical history – the age of “tick-box medicine”.

In order to identify which doctors to reward, QOF has to assess performance in terms of what can be measured. So, for example, we are set targets for blood pressure and cholesterol levels in those at risk of heart disease. This has contributed to an epidemic of over-treatment.

Patients who might once have been safely monitored while they made gradual lifestyle changes instead get pressed into taking drugs in order swiftly to get their indices to count towards the QOF target. Many of these prescriptions change a number in a lab test but produce no meaningful clinical benefit.

The focus on conditions with measurable indicators has also taken attention away from what cannot be counted. Since the introduction of QOF, improvements in care for less quantifiable diseases such as arthritis or anxiety have tailed off. There was an attempt to bring depression into QOF by compelling doctors to reduce the condition to a numerical score. This involved subjecting some of our most vulnerable patients to repeated, inane, multiple-choice questionnaires. GPs largely paid lip service to the requirement. It was quietly dropped.

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One conundrum that QOF has exposed is the question of what “best practice” is. The National Institute for Health and Care Excellence (NICE) publishes guidelines that set out gold-standard treatment for specific diseases, and QOF indicators are based on these. NICE guidelines became widely viewed as compulsory, with doctors believing that they were on dodgy ground in terms of medical law if they failed to comply.

This has been awful for patients with multiple conditions – once you’ve slavishly followed five guidelines in someone with five coexisting pathologies, they’re likely to be swallowing upwards of a dozen different pills. The resultant side effects frequently cause more harm than the illnesses.

NICE has recently changed the rubric that prefaces its guidelines, stressing that they are not mandatory and that they must be tailored to each individual patient. This would once simply have been good practice. That it has become necessary for NICE to spell it out shows just how far the profession has been degraded by the tick-box culture.

There are signs that this regrettable era might be starting to come to an end. Increasing numbers of doctors are reasserting the primacy of individual clinical judgement – and shared decision-making with informed patients – over diktats. But it remains hard to do so when strong financial imperatives are pulling in the opposite direction. Encouragingly, QOF has recently been abandoned in a few areas in England, and Scotland has replaced it wholesale with a scheme to incentivise nuanced and holistic local initiatives instead.

QOF did manage to iron out variations in treatment for a few specific conditions, but there has been no identifiable impact on overall mortality despite the countless prescriptions and blood tests it has generated. It is expected that it will soon be ditched nationally.

It may be that QOF’s biggest achievement will have been to underscore just how interpersonal and bespoke the art of medicine is. It is as if the profession were slowly waking from a bad dream – a nightmare in which doctors allowed themselves to be reduced to automatons, and their patients to pill-swallowing machines. 

This article appears in the 04 Oct 2017 issue of the New Statesman, How the rich got richer