Friday, 5 February 2010
To QOF or not to QOF ?
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 !'.