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Mangin and Toop1 provide an interesting overview of QOF, reflecting the many useful papers on aspects of QOF in the June issue of BJGP. Their criticisms of QOF make sense from a deontological (duty based) ethical perspective. It is far from clear that medicine is a deontological enterprise any longer.
There is a strong utilitarian perspective on QOF that sees the greatest good of the greatest number of patients as being a worthwhile objective. If this good can be measured then so much the better. (The felicific calculus is achieved.) Outcome measures would be ideal but intermediate process measures will do well enough. ‘Scientific’ measurements have apparently been made, and managers have ‘accurate’ spreadsheets and reports. Politicians can show that their targets have been met and that their ‘investment’ has ‘performed’ well. Individual GPs can play along with this game and reap the profits from it. So too can pharmaceutical companies, as under-treated illnesses and risk factors are systematically discovered and treated. It can all be justified as there is no shortage of under-treated disease and the rule of halves is so obviously a challenge that needs to be tackled.
General practice to this view is ‘Applied Public Health’, and the quirkiness of individual doctor-patient interactions is all very well, but ultimately stopping patients from smoking, and getting their cholesterol, blood pressure, and glucose levels normal is more important than the messy details of patient's lives. The patient becomes a means to a public-health goal, not an autonomous individual with their own specific goals. The doctor loses autonomy, and has to document deviance from guidance, rather than being trusted to do what is right in a given situation. Tallis describes this as ‘sessional functionaries robotically following guidelines.’
This utilitarian imperative is in alignment with public health and political imperatives but is directly at odds with a model of medicine based on individual doctors and patients reaching shared understanding of life, events, times, and illness.2 The ideals of patient-centred care, good consultation skills, respect for patient autonomy, the patient as an end in themselves, the doctor as a responsible agent, are all lost to this utilitarian mission. Much of the best general practice work of the last 30 years is rendered impotent under the new contract.3,4
The new contract is a reflection of the democratic deficit and the loss of trust in British medicine. Instead of trusting professionals to do their jobs properly we have now lost toleration for error, and instead we are subjected to the external tyrannies of measurement and regulation.
Goodhart's Law is in full flow. In time the measures used for QOF will cease to measure anything. However, for now the utilitarians are in the ascendant, and as a GP I will use my QOF score to get through appraisals and revalidation, and to earn some money. It is quite clear that I will get next to no credit or recognition for doing real general practice well.