Читать книгу The Complete Confessions of a GP - Benjamin Daniels - Страница 13

Lucy, the practice manager, popped her head around the door: ‘I’ve put you down for a visit to see Mrs Tucker. She’s had a funny turn and fallen over. Perhaps you could diagnose her as having had a stroke?’

It is January and our Quality and Outcomes Framework (QOF) targets are due in April. None of our patients has had a stroke in the last nine months. This should, of course, be a cause for celebration, but Lucy is not happy. If no one has a stroke before April, we will miss out on our ‘stroke target’. The government tells us that if a patient has a stroke, we need to refer him/her to the stroke specialist and then we’ll get five points! But if no one has a stroke, we miss out on the points and the money that comes with them. The more QOF points the practice earns, the more money the partners take home as profit. The practice manager also takes her cut as an Easter bonus if the surgery gets maximum points. In the world of general practice, points really do mean prizes.

Some older GPs hate disease guidelines. They feel that they take away our autonomy as doctors and rob us of our integrity and ability to make our own clinical decisions. I myself don’t begrudge guidelines at all. Strokes have been poorly managed in the community for years and some good research has shown that if someone has a stroke or a mini stroke and we sort out their cholesterol and blood pressure and send them to see a stroke specialist, we can genuinely reduce the chance of them having another stroke.

Mrs Tucker is 96 and lives in a nursing home nearby. She is severely demented and doesn’t know her own name. In her confusion she wanders around the nursing home and frequently takes a tumble. She had fallen over again today and could well have had a mini stroke. Having said that, she could just as easily have simply tripped over a stray Zimmer frame or slipped on a rogue Murray Mint. She was back to her normal self now and common sense told me that this lady would not benefit from a whole load of tests and new medications that in the long run would probably only increase her confusion and make her more likely to fall over.

I’m allowed to be puritanical because I’m not a partner and so don’t make any money from the QOF points. But would I have been tempted to diagnose Mrs Tucker as having had a stroke if I knew it meant that I would pocket some extra cash in April? Amazingly, in the vast majority of practices that I have worked in, the doctors are incredibly honest about achieving their targets truthfully. However, shouldn’t we remove the temptation altogether? Surely, doctors should be able to make sensible decisions about what is in the best interest of our patients without needing targets and cash incentives?