Monday, 8 March 2010

QOFing and tiffin.

Anyone fancy a spot of QOFing?

For those of us here at ND Central who have an artistic streak the great British institution of high culture known as the “Carry On” films are a must. They are on a par with Shakespeare and Wordsworth for their literary content and messages they convey about British society from the 1960s to date. Well one of the two last statements might be true?

One of the better of these intellectual treats, which vies with the film Carry on Screaming, as the best Carry on is the film “Carry on up the Khyber”.

This is a parody at various levels of the British involvement in India as well as the British class system and a complete pee take of Empire reflecting Britain’s decline as a world power and more recently as a “world-class” player in healthcare.

One of many scenes from the film that sticks in our younger then, and culturally uneducated minds, is the one when the incumbent governor, Sir Sidney Ruff Diamond, played by Sidney James, stops work for “tiffin”.

This is a clearly metaphor for the great British tea break. In order to “right a wrong” caused by his own wife’s infidelity Sir Sidney indulges in multiple liaisons with the wives of his adversary the Khasi which are euphemistically called tiffin.

Nothing hardcore, or even softcore, this was British 1960s innuendo at its peak.

In our younger years tiffin was a great source of hilarity as it meant doing nothing useful which we suspect many of those from the Indian subcontinent who will recall the largesse of Empire will no doubt relate to.

In the UK most GMS practices are engaging in a newer version of tiffin called “QOFing”.

QOF stands for the “Quality and Outcomes Framework” and at this time of year a lot of QOFing is going on to make up the maximum number of QOF points. This is the system of ticking government boxes whereby GPs can try to increase their income by ticking a series of boxes using the saying “points mean prizes”. The more points you have the more money your Practice gets. This is income that potentially GPs have some control over in contrast to the Global sum element of GP pay which is calculated using the transparently opaque formula known as the Carr-Hill formula.

Try Googling this one and see how easy it is for GPs to check how much they should be paid. Can you find the formula? We’ve been looking for years.

If something new is wanted by Gordon Pasha and his mandarins at the Department of Health that they do not want to pay for it is always “in the global sum”. Can you find it?

Government however can also change the rules and so each year there are less points with which to win prizes (= pay) and these points become harder to earn as the government can changes the rules merely “by consulting”.

British doctors are an intelligent group of fools led by idiots.

By this we mean that doctors are usually intelligent individuals who are trained to work individually, but not as team players, and so collectively are fools, as they cannot agree on whom to vote for, and so they appoint idiots as leaders of their profession.

So we return to QOFing and tiffin. Both are totally unproductive activities as per the Carry On films. The tiffin there achieved nothing useful but may have been fun for those involved and so does QOFing.

QOF is neither Quality, all the targets are dumbed down, or Outcomes, in terms of healthcare delivered to patients, as these are minimal but are all about box ticking for managers to justify their existence.

It means patients are “invited” to surgery for their healthcare for a whole series of mostly unnecessary things being done which clearly improves “Quality” and “Outcomes” for their GPs and their incomes and ticks managers’ boxes.

Take the simple example of angina.

This is cardiac chest pain which usually comes when exercising and used to be a clinical diagnosis. Clinical diagnosis means based on a doctor taking a history from a patient and examining them. In the vast majority of cases a simple trial of anti angina medication will establish the diagnosis at minimal cost.

The Party, however, knows better than the doctors so all “suspected” cases of angina must now have an exercise ECG. These used to be reserved for the cases where you weren’t sure but now all UK patients with angina should have one.

Result the cardiologists see no end of crap which a half brain dead decerebrate monkey of a medical student could work out was angina based purely on clinical grounds but no, as part of “Quality” and “Outcomes” tick box medicine, you cannot have angina, comrade patient, until you have had an exercise ECG.

So an expensive and unnecessary test done for most people but a Party box ticked showing “Quality” medical care and an “Outcome”.

Once you have had your exercise ECG you will probably get treated in the same way as before but it will just take longer.

Of course if your angina is serious and you need an “urgent” angiogram to tell the doctor whether you need a heart bypass operation this is not a QOF scoring item and you will probably wait a year or so to get one or die waiting. Still exercise ECGs are cheaper than angiograms so they are a “Quality” and “Outcome” issue.

First world medical care, for example a real “urgent” angiogram, if you need it, is not a “Quality” issue, nor is your death if you fail to get one an “Outcome” issue as long as you have angina and an exercise ECG that is all that is needed under QOF.

If your child has hayfever, and you get a repeat prescription for antihistamines for a 2 week period each year in June you will be invited for “a medication review” which achieves what? Nothing other than an inconvenience and a tick in a manager’s box to ensure your GP gets paid.

QOFing has generated a new form of “quality control” via the QOF visit each year for UK General Practices. Great you might think all those evil, overpaid, idle, golf playing GP scum banged to rights but just wait a moment.

One of the few of the team who actually read the nGMS contract and a few of the two thirds of GPs voted for it realized two fundamental flaws.

The less simple one was that this was a computer code generated contract. In other words if the code was on your hard disk when the Government software checked it at the end of the year you met the QOF and got paid.

Given a fairly logical, albeit impaired medically speaking structure, it would be relatively easy to write a program to create fictional consultations, recorded on a hard disk, plundered by Government software that would generate an income. If the codes are there the work is “done”.

QOF visits are done, each year usually by failing GPs who have no real work to do but like the money, and managers who have no ability or medical knowledge and they ask questions usually with the purpose of trying to intimidate practice staff and appear important. They have no ability and serve no useful function and certainly are incapable of detecting fraud as no-one asks the patients a fundamental question.

Have you actually had this treatment?

They prepare reports which say you have or haven’t ticked all the boxes. Lots of boxes ticked as a result of QOFing and tiffin.

Medical care is complex. Take a simple example you need you appendix removed because you have appendicitis. If it is not you die a very horrible and painful death.

Now under QOF appendicitis is not included but it might kill you. Appendicitis is therefore neither a “Quality” or “Outcome” issue for the Party but for the individual patient it could be a matter of life or death.

The second flaw is as follows: compare two different “Quality and Outcome” scenarios. One the high QOF scoring practice that uses administrative staff to read letters, extract data and code it. The doctors are absent or incompetent and they use the PCT funded out of hour’s service for any home visits which they do not do or they suggest that patients go to A&E.

You ring at 10.00hrs and are told the doctors are not available and to ring back after 18.30hrs the so called “core hours” which the practice does not provide.

The other scenario is the low scoring QOF Practice that actually see patients before they code data which is included in their QOF score and which NHS managers feel is failing. Here the GPs are available and on call and visit patients. They see their patients admit them and their appendix is removed with no complications due to early diagnosis.

A life saved but no “quality” points for doing so. You could apply this to a whole range of medical conditions not included in the QOF framework but attention is paid to only the highest QOF scoring practices or the lowest ones by those that supervise or “manage” quality in the NHS.

Which is the “better” practice?

These scenarios are not made up they are real. And managed by managers who ticked the boxes but missed the barn door obvious and got paid for doing so.

Good QOF point free medicine might save your life and is cost neutral to the Party. Good OOF scoring practice = good practice? Think about it. This scenario has happened more than once and no amount of QOFing or tiffin will stop it.

Patients only find out when they change practice or if they come to harm.
This is neither “Quality” healthcare or a successful “Outcome” but it is QOF.

Praise be to the Party for QOF which has improved “Quality” and “Outcomes” beyond any country in the world that purports to practise first world medicine.

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