The end of the QOFing year and why we are ashamed to be GPs.

QOFing is the process by which GPs in the United Kingdom who have signed the nGMS contract have a chance to increase their income above and beyond their fixed income determined by an unknown formula called the Carr Hill formula.

So as the QOF year end approaches we suspect that every nGMS GP and their practice staff will be trying to increase their income against a year on year decline due to “fixed” and decreasing Government payments via QOF and Carr Hill. This is in contrast to lawyers who have had their costs for obtaining medical information fixed by law (page 6) since 1998 but they are allowed to charge what they like as they work in a free market.

So at this weekend’s meeting at the infamous Café Michelle income and the subject of QOFing were discussed in depth as we know we are all about to take a huge hit in income not because we have worked less we know the reverse is the case. Most of our work is about treating real patients with real illnesses while QOFing is about treating Party defined illness and what the Party thinks is “good” medical practice. We have said before that QOF stands for neither Quality nor Outcomes just a mechanism to reduce GP pay.

As we discussed the lows and lows of Party dictated medical practice things like QOF, appraisal and revalidation and the prospect of the coming of CQC one of the team began to point out how low QOF “quality” indicators had become. They drew our attention to the Mental Health Indicators of this year’s QOF and to our own particular circumstances in our part of Northernshire.

Unusually for Northernshire we have an elite PCT staffed by those with Harvard and Yale MBAs and years of high flying corporate experience who out of the goodness of their hearts feel that this should all be brought to bear to improve our little part of Northernshire’s health service to standards enjoyed in the first world.

Furthermore in our patch we have a disproportionate number of our practice in the under fifties age group with almost universal employment in this group.

Now true mental illness occurs in all strata of society so given the above you would think that QOFing would be easy. Have a look at the nGMS Mental Health Indicators for 2011-12 and make your own mind up as to how much of the data being asked for has any relevance to a) any patient with a mental health illness and the treatment of their illness and b) anyone actually treating a patient’s mental illness other than an administrator. Then have a think about how does one go about collecting this patient and doctor useless information?

Most people in the UK with mental illness try to hide it because of the stigma the great British public attaches to it. If you have a broken arm people will happily sign your plaster of Paris pot but if you have a mental illness they will call you “mental” or “nutter” because they do not understand. There is even a TV advert trying to change this type of attitude.

Furthermore there is a recession and therefore pressure on jobs, even in areas with 100% employment, and so employees do not want time off work unless absolutely necessary.

Look at what QOF wants for mental health this year: BMI, alcohol, blood glucose, blood pressure, cholesterol tests and in women a record of a cervical smear (even if they have declined this test previously) all on an almost annual basis.

So you try different strategies letters inviting people in or phone calls and what we have found is that those who have mental illness are physically well and do not want to know. Strange that if you were fit and well in your twenties would you want to know or waste your time having a series of useless tests? After all most people know their height and if you have a set of bathroom scales why go all the way to the doctors to be weighed? How will that make your mental health better?

They are bright enough to realize that all of this information is totally unproductive to them and their healthcare compared with the real care their psychiatrists provide them with. The psychiatrists enable them to work and to raise families. The GP QOF indicators provide nothing other than data for NHS administrators.

Every psychiatrist’s letter we have read includes none of the above QOF indicators (apart from the odd mention of alcohol) so clearly this information is of no real use to those treating our patient’s real illness, their mental illness, as opposed to the Party’s defined “disease”.

After numerous rejections of our offers for QOF dictated “treatment” or “healthcare” together with a fair few abusive phone calls with those with more extreme mental illness who have told us in no uncertain terms where to stick the indicators we have decided to forego QOF retard mental healthcare and stick with what we were trained to do namely treat patients for their real medical conditions.

Not their QOF indicators.

Thus QOF has come to do what it has always wanted to do reduce GP incomes. If you read QOF indicators and their justification you would think there was some medical need for us to do all of QOF but remember that those who provide this “justification” would have in previous generations have told you that smoking and chewing gum improved concentration in airline pilots and so was a good thing.

No doubt the same people will be saying that QOFing, CQC and appraisal all have similar benefits for patients. A delusion is a belief in the absence of reality. A lot of people in medicine are clearly deluded should they be on a QOF mental health register? And what would they do when we invite them to attend for totally unnecessary and completely useless tests?

So after a great deal of thought on this we have to apologize to any patient who has a mental illness for wasting their time. We have to apologize for being GPs who sometimes treat real patients for real illnesses for which we receive no extra payment and for wasting our patients’ time collecting information for administrators. We are also ashamed to have to prostitute ourselves on the altar of p*ss poor medicine in order to earn income called QOF.

Doctors are meant to be responsible people and it is said that all that is needed for evil to succeed is for good men (and women) to do nothing. Medicine is full of loads of good people and you can spot the most godly of these by the number of QOF points they have. Especially in mental health.

Praise be to the Party for stuffing the faces of GPs with gold to provide “quality” care. When it comes to stuffing the faces of GPs with crap medicine to provide substandard patient useless care we take exception.

Is there a QOF code for that?

QOF and squeegee gangs.

We wonder how many patients may have had at this time of year letters along the following lines (we have put our real thoughts in brackets):

The doctor/nurse/adminstrator in charge of your (insert name of a Party determined illness) has noticed that you have not had the following:

blood test/blood pressure/asthma test/cholesterol test/(your head shoved down a toilet test for no reason other than QOF says we should do so test).

As part of the practice’s commitment to your health and well being (that’s a pack of lies we want to get paid if we tell the truth) we invite you to make an appointment for this with a doctor/nurse/healthcare assistant.

It is vital that you have this test to ensure your continued good health (if you don’t all your sexual organs will shrival and drop off or some other implied threat inserted here)

Please ring on the above number to arrange for this test.

Signed


Doctor/Nurse/Another.

Now we bet no GP will have ever have sent such a letter or asked staff to ring certain patients and “invite” them to come in for some “tests”.

The annual GP QOFing season is on so if you are a patient look out for numerous invites to perform tests to ensure that your Party approved illness is well “managed” by the medical process of ticking a box determined by some dullard in Whitehall the sole purpose of which is to try and reduce payment to your evil overpaid GP. Any real illness can be treated usually without all these mostly unnecessary extra tests done for no medical benefit other than doctors’ pay reduction.

A simple example would be if you have a mental illness do you need your cholesterol checked every year if you are well? Would your identical twin without any mental or other illness get the same intensive “treatment” as you? No discrimination here comrades as all patients are equal in the NHS and we are all in it together . . .

We think that as a patient with a long term condition being QOFed is a bit like being squeegeed at the traffic lights. Your windscreen is clean as you are well and so you get from your doctor a totally unnecessary load of soap and old flannel packaged to make it look like it is something useful to you when you don’t actually need it to make someone a fast buck.

Soap and old flannel will we are sure appeal to anyone who went to a public school especially if administered in the showers by a matron in a uniform but to anyone else it will be a load of froth on your windscreen - completely pointless and very annoying.

Praise be to the Party for ensuring that year on year GPs and their staff are spending more time squeeging windscreens than doing real medicine. Don’t worry if you can’t see your GP with real illness. If their QOF points are squeegee clean then they are Party approved excellent GPs for ticking all the Party boxes while ignoring your real healthcare needs. QOF you know it makes sense medicine.

Not.

Top tips from a money saving GP expert.

We thought we might have a laugh and introduce a series of ideas on how the NHS could save loads of money for very little effort and perhaps as a side effect, in contrast to central Party diktats, improve patient care. Here is our first (possibly of a few?) GP money saving expert top tips.

When we were junior grunts the diagnosis of angina was clinical. This meant talking to patients and examining them without ticking any boxes and coming up with a differential diagnosis or list of things that you thought as a professional, rather than a Party tick boxer, the patient might be suffering from.

In the case of angina, classically described as central crushing chest pain occurring on exertion radiating into the neck and down the left arm causing the sufferer to slow or cease exertion and the pain resolves with rest, all one needed to try was a trial of a few pence worth of a drug to see if this eased the symptoms. If it worked the diagnosis was likely and then other more expensive drugs could be added to control the symptoms.

With advances in pharmacology the control of symptoms by drugs was added to by the use of preventative drugs like aspirins and statins. All good old fashion general practice and clinical medicine – simple, cheap and safe.

For more difficult cases, or where the diagnosis was not clear cut, then referral to a general physician or a cardiologist might be required who then might order an exercise ECG or stress test or proceed to more invasive tests if bypass surgery was considered. However most cases could be managed cheaply in general practice.

Such medicine was not considered good enough by the Party who via the QOF (Quality and Outcomes Framework) introduced the “quality” angina framework which if you wish to you can read it here.

So now instead of simple cheap GP management between 40-90% of patients are now expected to be referred to a hospital. Not the minority who used to be referred there but the majority will have to be referred in order to maximize GP income and tick the QOF boxes to show how "good" a doctor you are.

So now for every patient with angina either £ 93 of exercise ECG or £ 215 to see a cardiologist (click 2 Outpatient attendances) will be incurred to ensure that the GP is Party compliant and gets paid. And that is in addition to what was done previously.

If you look here you can see some figures for how many people in the UK have angina. So if you round up the figure to 2 million the costs of treating angina have gone up from a few pounds in general practice per patient to a few hundred pounds per patient if you follow the Party approved protocol.

Our former leaders felt that this cheap and cheerful approach which helped patients was not worthy of those who had not had the misfortune of ever working in medicine and so these wise idiots overnight increased the need for unnecessary investigation of the majority of those with angina by introducing centralized QOF control of medical practice. Even the Party’s tame GP attack muppet does not approve.

This is akin to looking in a field and saying there is a four legged animal with a white fleece, a black face, that chews grass and emits baah sounds and this looks like a sheep. It is indeed likely to be a sheep and does not require further investigation unless you suspect that the 3 foot long creature might be a blue whale in disguise as a sheep in which case far more expensive tests than the mark one eyeball might be required for example DNA analysis to determine if your case of angina was in fact a case of blue whale in sheep’s clothing. Such DNA testing is now required for all sheep by the Party to exclude the odd blue whale out there.

Medical training in the NHS has generally tried to minimize over investigation in order to get a result but Za Nu Labour’s QOF has probably increased over investigation with no discernable benefit in terms of “outcome” but as long as targets and tick boxes are met we know that “quality” care has been given.

Clinical medicine is ever changing and what might be de rigueur today could be heresy tomorrow. Ticking QOF boxes restricts clinical freedom and imposition of centrally dictated “outcomes” and economic control will severely restrict medical advancement and compromise patient care. For if in order to get paid the doctor has to tick the box as opposed to give a patient a better treatment than QOF allows this will clearly compromise patient care as QOF takes time to change.

Praise be to the Party for dictating how we should waste money. This is the sort of thing that GP consortia should be tackling but they can only do this if they come up with some NICE ideas that are Monitored and approved by the Board and its ultimate controller.

So we must now be looking forward to a new GP led free from central control NHS and money saving ideas like this will be so simple to do, won’t they?

Statistics, QOF, fraud and detection in the NHS.

While busily waiting for the next patient to attend during our Party imposed one 10 minute appointment slot suits all, 2.5 hours of booked surgery as opposes to 1 hour of actual of consultation time, we used the down time to trawl the web and found this interesting piece on a BBC News website.

Now if you have a scientific background this makes perfect sense.

If you only have a Harvard or Yale MBA, which all our local PCT managers have, even the cleaners, then you can be sure they understand this excellent piece on how statistics can make you a killer when in fact you are not. For just listen to them act as judge and jury on any topic while they are busy working.

Two examples from general practice illustrate this.

The first involves their policing of the QOF points. QOF stands for neither a Quality nor an Outcomes Framework.

It merely means a box has been ticked on a computer program. You do not need to see any patient, or give any patient any treatment, just tick the box. And, as a result, you, as a GP can get paid. Simples.

So a practice that has average number of QOF points will not incur any investigation even though none of its patients are receiving any treatment but will still get paid.

Now the NHS has “robust” anti fraud policies so that no GP with no qualifications can ever get away with prescribing creosote for toothache – we jest not read down this link towards the bottom and another did the same too read the small print at the bottom. The NHS has some of the finest forensic brains in the fraud busting world which would make CSI seem like rank amateurs for the only bit of a CSI episode they could understand was the adverts.

They employ advanced fraud busting techniques like if you get the top end of QOF points you are bent.

Of course in the same way that the “boffs” in their class at school got 98-99% scores in exams it was because they were “bent” not clever, or when they are grown up good doctors, while the fact your average PCT fraud buster got 40% in their exams was ‘cause the ref weren’t on their side.

If you are in the bottom of QOF scorers you are also bent. For surely you are not looking after patients? This might be the case but there might be another reason for this, for example the patients do not come to clinics.

And indeed this might be a combination of the above factors. A high scoring practice on paper but when you actually start looking at the patient care it is nonexistent?

However if you are in the top of the local QOF points or the bottom ones you are suspect and will receive the third degree.

This is the average PCT fraud busters approach which is similar to those in Whitehall who saw all of those Weapons of Mass Destruction from afar but in fact they saw nothing but they were still there, allegdedly.

This brings us onto the second argument doing the rounds of the thick regarding PCTs and their Harvard MBAs saying that referrals are too high.

Is that the same as saying illness is too high? “Comrade Zhivago you have referred too many cases of TB from your labour camp. Please stop this as we have overspent our TB treatment budget and you are referring above the 5 year plan targets”.

Is a high referring practice a “poor” practice because it refers everything correctly or, is it a “poor” practice because the GPs are crap and can’t manage simple things that better practices could?

Equally is a low referring practice a crap practice because it does not identify and therefore ignores disease and fails to treat it, or, is it a good practice because it treats disease that does not need to be referred to hospital?

Both these instances affect GPs and if you read the link you might start to realize that some things can appear to be real not because they are but they can also occur by chance.

If you think the odds are small then try this one for size. We wrote this piece on Friday night at the Café Michelle after reading it in the afternoon. We were going to proof read it and publish it today expecting no-one else would have spotted the original piece in the link above.

What are the odds of 2 medical bloggers, one a consultant, respect Dr G, the other a GP reading the same article and being prompted to post their thoughts on the same day? Statistical chance or conspiracy? You decide and you can read Dr Grumble’s thoughts on the same item here.

Praise be to the Party whose knowledge of statistics is second only to their knowledge of healthcare and how to run it. We are in such good hands.

PS Seems another medical blogger has read our inspiration for this piece the Witch Doctor. Did all of us have a slow Friday afternoon and “randomly” click on the BBC News website? Cue X-Files music . . .