Show Me The Money!

QOF Losing Steam

In the matter of GP's, and indeed Doctor's, much has been said about their future role as the new Guardian's of Primary Care. Unfortunately, that seems to becoming a bit of a 'poisoned chalice', as it is clear that they will probably be damned if Lansley's 'experiment' doesn't work and probably if it does, because in achieving the goals of Government they will become both the provider and the arbiter of provision. It will no longer be the PCT or NICE who will be on the receiving end of patient wrath, it will be the GP's themselves.

It is also important to examine how this unique 36,000 or so Doctors structure their relationship, with the State, because it is singularly different from the rules and practises that rest of society lives by and with. Most GP's are in fact 'small businessman' or indeed not so small. They are 'contractors' paid fees for the provision of Primary Care services to their patients. Quite a few are Limited Liability Companies, and some are already 'Consortia' in a loose coalition of practises, working out of Health Centres provided by Local Government, for which they pay rental. So how come we (the taxpayer) contribute to and manage their pension fund within the NHS? No-one that I can think of,  has this sort of 'special' relationship with their client or customer. 'Bob the builder' would dearly love someone to pay a sizable chunk of his pension contributions and guarantee him a good percentage of his final income from 60, but it ain't gonna happen, because he's a 'subbie', just like you. Difference is he will be incapable of working after 60, because he's 'knackered'! You can retire at 60, alright if you don't commit suicide first, with a gold plated pension, we (the prole's) can only dream of!

This is all part of the relationship that doctors have with society. All take, no give, 'loads a money' for their business, especially payment by results for s**t protocols that do not produce any real reduction in the ultimate end point (that's death!), but bags of surrogate end points like slightly lower BP or worse; lower LDL, that prove absolutely f**k all! Oh and don't forget the virtual exemption from any likelihood of ordure if you cause a patient to die, (although if you s**g one, watch out!). Some, albeit it a few, are making in excess of £250k, for office hours! Most make £105K or more. Some single handed practises in remote areas make up to £300k.

Almost all of you GP's, either couldn't be arsed to turn up to the recent BMA special conference or bother even vote for action, against reforms and took the 'easy' route. But, you were all up in arms about the idea of working to 65 as us poor mortals are going to have to, and even prepared to strike, or retire from the battlefield, on the grounds of self interest! As Pulse revealed, lots of GP's are already on the boards of Private Health care providers and will have a vested interest in supporting  their own Commissioning ambitions. This highlights some of  those in the Profession's, constant desire to command and control the situation for their own pecuniary advantage, whilst trotting out the usual rubbish about 'putting patients first'. A significant minority of GP's it seems, are looking forward to Commissioning as a vehicle to advance their careers and their pay.

Well, since Nye Bevan "stuffed their mouths with gold" in 1948, Doctors have been  overly concerned with the money rather than the welfare of their patients. In 2004, when they were able to 'palm off' the out of hours responsibilities to the PCT's, they could hardly believe their luck in getting away with this for a mere 6% of fees. This led to almost all of the call outs being handled by the Private Sector providers, who got away with murder, by the recruitment of foreign or newly qualified doctors, in an attempt to maximise profit at the expense of good care provision. In addition, the deal brokered by Blair's cronies with the BMA, launched on a 'clueless' public the Quality Outcomes Framework, which boosted pay so much that an additional £1.7 billion more than estimates, was expended for the somewhat dubious outcomes I highlighted earlier.

So GP's are extremely good at managing their finances, but not quite so good at managing their clients health, unless of course it's ensuring that said patient is adhering to the QOF protocol they have been placed on, which is the management of their finance because of the 'payment by result' they receive for this duty. And what is the method of 'measuring' the outcome? It is called a surrogate end point; so if a GP 'statinates' a patient, achieving a lower LDL level, will elicit the payment. Quite a few Doctors are aware that this will not make a difference to;

• Any Woman
• Any Man who is not a high risk or has had no CVD/CHD.
• Any Man who is at risk but has had no CVD/CHD.

In fact there is very weak evidence to support the use of statin's with patients, even at high risk, but with a previous CVD/CHD event, but the reduction is almost not significant and a large body of scientists actually believe that statin's are working in a different way from their mechanism design. Many Doctors know all about the risks and the lack of evidence for statin use, but cynically do not do anything about it. Dr Phil Whitaker, who is also an author, recently said " My GP colleagues and I have become press ganged into the role of pill-pushers, the tyranny of QOF subjecting patients to bewildering and sometimes injurious choices of drug, irrespective of circumstances". Doctors can 'exception code' patients, and some do. But do this with more than few and the PCT 'Stasi' will be onto you.

If you really want to upset Lansley's dream of an NHS peopled by 'right thinking' private consortia, guided by the Kings Fund, Kaiser et al, then commit some acts of disobedience like exception coding all your patients and tell the 'thought police' to take a hike, or refuse to cooperate with the ConDem's grand plan. Just do something that isn't related to your personal wealth. Just for once!