At the annual conference of the Royal College of General Practitioners held in Glasgow (Oct 1st to 3rd) Shona Robison the Scottish Government Health Minister announced the demise of the “Quality Outcomes Framework” (QOF), to the applause of 2000 GPs. The QOF was embedded in the 2004 GP contract and awarded GPs points, and income, on the basis of fulfilling certain tasks such as recording patients’ blood pressure and smoking status. GPs, medical students and doctors generally, are very good at fulfilling set tasks and jumping hurdles; they’ve been doing it all their lives. The 2004 QOF was easy. Most of the GPs got near maximum points. So the QOF evolved. It became more complicated, more bureaucratic, and more burdensome. I was about to say the paperwork mushroomed, but it would be more accurate to say the electronics went haywire, and before they knew it, GPs were spending twelve hour days glued to computer screens, fulfilling more and more obscure tasks.
Running parallel to the contractual obligations were the requirements of continuous professional development (CPD). Previously, GPs were required to demonstrate maintenance of professional standards largely by demonstrating attendance at a number of medical education meetings or courses. Just before the inauguration of the new contract, annual GP appraisal was introduced as a means of monitoring GP CPD, checking not only that GPs were putting in the CPD hours, but were also doing so in a planned way based on their own (and their appraiser’s) perception of their educational needs. GPs were required to “reflect” on their educational experience. Appraisal was put in place not long after the trial and conviction on 31/1/00 of Dr Harold Shipman who was found guilty of the murder of fifteen of his patients. The Shipman Inquiry commenced on 1/9/00 and ran for about 2 years. Dr Shipman committed suicide in prison on 13/1/04. By an extraordinary non sequitur sections of the lay press somehow developed the notion that the purpose of GP appraisal was “to prevent another Shipman”. Any newspaper article on the subject of GP appraisal would almost certainly mention the name Harold Shipman. Then, as with QOF, the paperwork, or electronic-work, of appraisal also began to burgeon and grow more complex. The medical profession began to suspect that it was being punished and made to suffer as an expiation and apology to the public, because a serial killer happened to have been a doctor. This was felt all the more keenly as the demands of QOF and appraisal became more surreal. It is well known that if you wish not only to punish people but also to damage them psychologically, you give them a futile task like writing out lines at school, or painting coal white in the army.
Hence GPs would be subjected to a directive like this:
Reflecting on the practice’s outpatient referral dataset and comparison with other practices, list the internal factors that contribute to any variation in the practice overall and individual GP referral patterns (eg clinical expertise; learning needs; demographic profile etc). If your discussions around activity levels confirm your current practice; outline specific areas of your own practice internal to the practice which are aimed at supporting independent management in the community and avoiding potentially unnecessary referrals. List a minimum of three useful elements which could be shared with other practices.
I’m not sure, but I think it means, are you referring too many people to hospital, and can you think of a few ways of cutting it out?
When I read the above paragraph about three years ago, I wrote an incensed letter to a prestigious medical journal, which started thus:
I would like to invite you into Fellowship of an august medical society, DAMASK. DAMASK stands for Doctors Against Muddle and So-called Quality (with a capital K). You will be relieved to hear there is no subscription, no journal, no conference, and no AGM. It’s more of a kind of freemasonry than a society. All that is required of you is that, when you are attending a medical meeting at which somebody who doesn’t know anything about medicine propounds something utterly preposterous, you stand up and make, either figuratively or literally, a bad smell.
I got an email back from the journal to say yes, we’ll print that. We’ll just run it by the letters editor.
Then, stony silence.
I find that stony silence is the modern way. In this day when communication was never easier, it is only the passage of time that tells you you have become a “lapsed action”. We have email we have twitter we have facebook we have text we have SMS we have smart phones we have landlines we have The Royal Mail. We even have, I discovered while dining with friends this weekend, “Snapchat”. The defining characteristic of Snapchat is that the message dissolves in the ether after 10 seconds. Maybe my prestigious journal snapchatted, “On mature consideration, we’ve decided your piece is too inflammatory.” And I was just too slow on the uptake. I would have accepted that. It’s the silence I can’t abide.
(Incidentally, why snapchat? I can only think it’s useful if you’re into sexting or internet trawling. You know you’re going to send out something you regret, so get your expression of regret in first.)
Medicine has learned a great deal from the world of aviation in terms of managing risk through the use of checklists. Medicine – actually any large corporate activity – should also adopt the aviation practice of “read back”. Read back is vital on the r/t. I recall with nostalgia the romantic poetry exchanged between the control tower and the big jets on the runway at Glasgow while I, a callow youth, was doing circuits and bumps in the Chipmunk. “BA 53 you are clear to Heathrow via White Nine, Amber One, to cross Lanark and Talla at flight level 55 and to climb when instructed by Scottish radar to flight level 320 today.”
And it would be read back, verbatim.
“Read back correct.”
Falling foul of a lapsed action is one of the great dispiriting experiences of modern life. When you write a letter to a bank, or a utility company, or the Inland Revenue, or a multinational conglomerate, and get no reply, you are like a pilot in a stricken aircraft sending out a Mayday call and hearing nothing in your headphones except static.
But here I must write in praise of Shona Robison, who had the courtesy to let us know she is scrapping QOF. Of course, being a politician, she said something along the lines of, “QOF was of its time; but it has outgrown its usefulness and is no longer fit for purpose.” It’s not true. It was never fit for purpose. The politicians might not know that, but the doctors always knew it. I like to think we went along with it out of naivety rather than out of cynicism.
Cato the Elder used to end all his addresses to the Roman Senate by reminding them, no matter the topic of discourse, “Oh – and by the way, Carthage must be destroyed.” He knew that if he said it often enough, one day it would happen. For a period of about five years I adopted this technique and made a point of saying, at the end of any and every medical meeting I attended, “Oh – and by the way, the QOF must be destroyed.” I made myself an utter pain in the neck. My colleagues would say, “James, put a sock in it.”
It just shows you. You plug away at something. You think your effort is futile. You think you’re trapped. But you’re not.