To QOF or not to QOF ?

Quality Outcome Frameworks, that vehicle to keep the proletariat 'healthy' comes under fire once more. This time in an area dear to my heart; Diabetes.

It's always interesting to look at what NICE recommends and examine from time to time that which is ignored and that which is adopted from the voluminous output of this august body. When there's a few quid for the cash strapped GP's we find it to be adopted without question. When it's something that is valueless, in monetary terms it seems to take a back seat. What a surprise !

NICE does a lot, some of it is even useful (rarely), some of it benign and some of it positively dangerous, such as the guidance for QOF targets for Diabetes outcomes. The Lancet, last week published the outcome of a study into the application of these targets in the management of 50,000 patients in the UK showing clearly that the pursuit of HbA1c levels below 7.0 was putting patients at risk for CVD events. Dr George Kassianos, a GP and research fellow in Cardiology went further suggesting that tight glycaemic controls for Type 2 patients was in fact dangerous and should be amended to 7.5% instead of the current 6.5%.

Diabetics generally have a tough time of it in the NHS with being 'over managed'. Constantly being told to lose weight, that they should lower cholesterol, BP and keep within very strict limits for glucose control. Practices are paid by results to achieve these targets so patients become a cog in the machinery of practice income instead of a human being with individual needs and problems that need addressing with patient centred protocols. The money gets in the way and the so called research that backs up the QOF is often an ill thought out hypothesis with little or no evidence to back it save for that from the drug company that thought it up. And we know how impartial their research is !

This study highlights the dangers to the extent that mortality was 52% higher in those with HbA1c levels in the lowest tenth of the study at 6.4%. That's 2500  patients ! Yes that's correct 2500 people died because they were put on 'tight' control protocols by a QOF ! Yet I've looked for a response to this study from Diabetes UK,  the 'leading' charity and I can find stuff all !

I have long known about the piss poor protocols and treatments available to Diabetics in the NHS which eats up a huge portion of the budget, with drugs, insulin, dieticians, and so on and so on but it never seems that anyone really looks at the Science to see if the money is well spent or the patient is getting better. Because the former is a lucrative 'gravy train' of ever increasing length and the concesus on the latter is, it will never happen. It seems it is in the interests of all, except the patient of course, to maintain the 'status quo' and now we find that a major element in the treatment plan is so flawed as to be deadly ! It should have provoked an immediate rethink of policy but no doubt NICE will have to conduct a long and expensive review of the policy (QOF DM23) prior to reducing the target. In the meantime a few (hundreds ?) may actually die ! It should be urgently amended for the current year, not next !

Still, what does it matter, the cash is coming in and there's plenty more diabetics. It's not like we are a looking at a famine of people to treat. More are diagnosed every day due to the crap advice doled out by the Agencies of Government and the kindness of the soft drinks industry in feeding us High Fructose Corn Syrup. I always say if you are looking for the culprit for most events that cause harm, especially in Medicine; 'follow the money !'.

Frustration

It is without doubt, a travesty that defies logic, that Jane Barton has escaped the ultimate sanction that she rightly deserved. It is once again the destruction of an expectation of Justice, that most felt to be inevitable and desired. Ann Reeves, who fought long and hard for the opportunity to bring this profligate over subscriber of opiates to vulnerable and now dead patients, is both bitter and outraged.

At the same time 'teflon' Tony Blair was expounding his singularly individual account of how he got us into our own version of Vietnam; the Iraq War. With a confidence bordering on Evangelism he absolved himself of all blame, piling it on the head (now detached) of Saddam Hussien.

Both events are a travesty of the natural Justice that we all feel should be meted out to those that are guilty of sending people to their deaths, be it on the field of battle, or the Wards of Gosport Memorial Hospital. Not because people die in either place that is given, but because they died without need, without a purpose that their loved one's feel, they can espouse or understand.

Tony Blair continues to earn the inflated and undeserved reward that he would never have been heir to without the bodies he has clambered over. His £15 million a year income (as reported in the Sunday Mirror, so it must be true) would never have been possible without his unholy compact with Bush to invade both Iraq and Afghanistan. He would have been consigned to a different history, of Memoir and Scholarly endeavour, with a comfortable, but hardly lavish lifestyle.

Jane Barton too, continues albeit with some restriction, to continue the practise of Medicine. Probably with a lifestyle, that the victims of her particular penchant for profligacy with syringe driven morphine, would never have achieved, presupposing of course that were not already dead; which is a fairly certain curtailment of one's ability to earn a crust.

Blair seems to have stolen Barton's dubious victory from the limelight, which only the most paranoid would believe to have been a plan rather than kismet. But, in a country where basic, intuitive belief in fundamental justice, is now so eroded, we expect almost anything of the machinery of the State. One thing that does stand out as significant, is the lack of  condemnation of Jane Barton by her peers. The medical bloggers, especially the Doctors have continually highlighted the case and roundly condemned the verdict, with splenetic utterings that are both deserved and even ingenious. You can read them at the side of this blog.

One however, stands out in his silence, which as I generally admire him is almost hurtfull, but with a nom de plume, linked with another poisoner of historical fame, maybe he thought comment to be inappropriate. That's as maybe, where are the other 30,000's view of this consumate figure of evil, in the eye's of her victims loved one's. If it comes to that, where are these men and women of letters views, on the litany of disasters, nigligence, accidents and sheer stupidity perpetrated in OUR NHS almost daily. Do they think that we do not notice their silence ? Is it too much for the servants of the Taxpayer to side publicly with their constituency, or am I being too dense ?

Doctors have been known to kill as Shipman proved but their ability to evade the Law is both tragic and counter to all the tenets that we as citizens have to abide by. Have we created a cohort in Society that has the power over life and death with none of the responsibility attached ? You would almost believe they were Politicians or Policemen.