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David Carvel has written to comment on the high proportion of papers from overseas in September's BJGP (page 883). This month there is only one (or two, depending on how you count the Republic of Ireland) — an interesting study from Denmark on delay in diagnosis of lung cancer that echoes the finding in another paper that we published recently, that negative chest X-rays don't rule out the diagnosis (page 863). However, the rest is from the British Isles: a comparison of communication between white or South Asian patients and their doctors (page 869), with the non-English speakers finishing up with more questioning and less information.
On page 848 there is the report of a trial showing some improved surveillance of drug users' hepatitis C status by one simple intervention, but on page 842 there is little effect from another simple intervention to enhance the care of patients with hypertension. Most confusing, or disheartening, is the systematic review of interventions to increase consultation times, which identified almost no health gains from the change (page 876). This is an intriguing conclusion, since an earlier review published by the same authors showed that observational studies did show advantages from longer consultations.1 The difference may have something to do with established consulting behaviour, and how long it takes doctors to adapt to change.
David Carvel wants us to take his letter in the tongue-in-cheek spirit in which it was written, but he touches on a vital question. The worry from the editorial office is that it represents more of UK insularity — the ‘Fog in the Channel: Europe isolated’ syndrome. While he worries about how to apply the results of Dutch studies to his own practice, we worry much more about what the international community is to make of some of the UK research that we publish (and, in passing, he's right to imply that we worry about the ‘B’ of BJGP). This month, quite by chance the problem is illustrated by three papers about the workings of the UK Quality and Outcomes Framework (QOF). All three provide valuable data about the details of how the system is working in practice. We have the association with type of contract, with the suspicion that practices working with entirely employed doctors may be providing poor value for money (page 825) and the suggestion (again) that in clinical care small practices seem to score as well as larger ones (page 830). The study on page 836 explores the effect of the Byzantine formula for adjusting prevalence, and concludes that the system has introduced substantial new inequalities into GPs' pay. In the accompanying leader on page 819, Toby Lipman contrasts this protocol driven care with the ‘humanity and unpredictability’ of traditional general practice and is fearful of the latter's capacity to survive the onslaught. Dougal Jefferies, in a letter of reply to his critics on page 885, goes one step further and argues for active resistance.
The BJGP has to try to sustain an international appeal in order to continue as a serious scientific journal, while recognising that the College and the majority of the readership is much more immediately concerned with what is going on on our doorstep, and it's likely that we are going to have lots of papers submitted that examine the effects of the QOF. Others have written that the new UK contract is a bold and radical experiment, and international observers will be keen to see how or whether it works, so such studies may enhance the Journal's appeal. But for those like Dougal Jefferies (and, it should be obvious by now, myself) who deplore the centralist, dirigiste approach that underpins the QOF, a curious late flowering version of Soviet medicine, and who despair of where it will lead primary care in the UK, it is all very depressing. If other countries follow the structure, then the research will prove invaluable for the international community, but I fear it is leading us all up a blind and very lonely alley.