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Logo of brjgenpracRCGP homepageJ R Coll Gen Pract at PubMed CentralBJGP at RCGPBJGP at RCGP
Br J Gen Pract. 2009 July 1; 59(564): 546–547.
PMCID: PMC2702027

Patient care — crunch time

The NHS carried me into the world, slapped my backside and gave me breath, kept me warm and fed, vaccinated me, supplied the occasional antibiotic, filled my teeth (mercury and gold), X-rayed me and reassured me, trained me for my lifelong profession, brought my son into the world and saved his life, sorted out my wife's pain, embraced my father and father-in-law as they both slipped comfortably to the grave, and now turns its attention back to me as my family history looms in view. Thank you.

Only doctors born in the early 1920s will now remember practising in Britain before the inception of the NHS in 1948.

My professional career in primary care has enjoyed a halcyon time, largely able to consider patient care in an atmosphere unmuddied by constraints of cost and the patient's ability to pay.

True, the occasional momentary dryness of mouth when I stand, goserelin poised, reminds me that all this of course has to be paid for somewhere, but this is not a conflicting consideration at the immediate coal face of patient care.

Our regulatory authorities underpin these privileges, guiding us to make patient care our first concern — and never to abuse the trust that our patients place in us.

So, all is well …

Meanwhile, in other spheres a very chill wind has recently blown through our financial world. As we try to understand and react appropriately to this new threat we struggle with the need to apportion blame — on the banking sector and its pursuit of bonus culture at the expense of fiscal prudence, on the apparent rewarding of failure, and on ineffective regulatory bodies. The love of money fuelling unethical behaviour? Never to trust again?

The Quality and Outcomes Framework (QOF) was introduced to British general practice in 2004 rewarding us for implementing good practice and paying us a bonus dependent on achievement.

In the beginning QOF was embraced by the majority of practices across the country — the criteria were achievable and financial rewards were significant. There was ethical comfort to be taken from a countrywide raising of the standard of patient care in many clinical areas.

However, subsequent years have become concerning with year on year tinkering. New QOF domains have been introduced and criteria tightened, no doubt with the aim of improving patient care, but with the accompanying effect of making targets, and their linked financial bonus, more difficult to achieve.

Further, year on year, new GPs are inducted into this bonus culture and will know nothing else. Will I, as my life comes to a close, be able to exercise choice and place my trust in a practitioner who remembers patient care before QOF?

As chronic illness overtakes me, and were I to have the opportunity, what would be in my Charter for Patient Care?


  1. The clinical care given to me will enable me to trust the giver's altruism and enable me to rest safe in the knowledge that it is based on clinical need rather than the pursuit of a financial bonus. While I respect and understand the intelligence underpinning QOF, I would hope that it is always applied with wisdom, and with regard to my humanity.
  2. I expect the care that I may receive to be given patiently.
    After my coronary I would expect to be allowed to introduce my raft of therapeutics gradually, building up a knowledge of their effects and side effects. Should I fail to meet my targets in cholesterol and HbA1c I do not want to be regarded as ‘sub-prime’.
    The care will also be based upon longstanding continuity, with the same physician if possible. The safety net of care will remain patiently in place from year to year, until I need it when I fall.
  3. I will not be inclined to diminish the care I give as a patient. I am buoyed up daily in practice by a shared understanding from my patients. They understand when we come to the ethical dilemma, the uncertainty of the diagnosis or the prescribing of time, or more bluntly, when therapeutic options have been exhausted. This understanding cares for me as the physician, and is based on mutual respect and trust.
  4. My cares as a patient will be acknowledged and addressed.
    I will know that my physician will have no conflict of interest in acting as my advocate. Money will not get in the way. I will be able to continue trusting.

I expect QOF has achieved an improvement in patient care, and no doubt outcomes, across a range of chronic disease illness nationwide. I suppose the main focus of my concern is where we go from here. I would urge caution in tipping the delicate balance too far in favour of a bonus culture. I hope our regulators will share this view in theory and action, but above all, I hope the prime directive imbued in future generations of doctors will be the ethos of altruistic patient care, untarnished by a toxic bonus culture.

We can always learn much about professional medical practice from the worlds around us — whether the currency under consideration is fiscal, or the harder to quantify world of caring. Let us pay heed then to the experiences of our colleagues in the financial sector and their experience of the primal human response when trust is lost.

In this climate, can we afford not to?

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners