8:30 Monday evening and Mr Jones walks in to the consulting room. He and the doctor are new to each other. What could possibly go wrong.
“Good evening Mr Jones”.
Silence is the answer. No verbal response, downcast eyes and a flickering of the lip.
The doctor watches and his diagnostic feelers start to quiver-albeit slowly as it has been rather a long day. Mr Jones has arrived halfway through his third surgery of the day, 12 hours after the start of the first. Gordon Brown has certainly left his mark on primary care-extended hours surgeries a boon for patients?
So what next-the doctor starts to think, what goes through his mind? What should go through his mind? He tries to focus-on the patient in front of him, not on the distracting forces around him. What are those forces-what can distract him from the single most important aspect of his work?
To understand how best to help the patient, we may first need to understand how best to help ourselves as doctors. To clear the mind, to remain alert, psychologically well, and concentrate our efforts during those sacred 10 minutes. This is not easy, especially when some factors are out of our control. We find ourselves making working, lifestyle and financial choices which can all affect patient care if not handled carefully. We work within a practice, and have obligations to our partners as well as our patients. We may be part of a family and must also fulfil our role at home. We have bills to pay, maybe a mortgage, as do our partners at work and this also hovers in the back of our minds during the working day. How do we ensure that we separate the patient’s needs from our own? There has been much published over the years about the doctor/patient relationship-much of it very good at the time, and many aspects of it still relevant today. I would argue that this relationship is under threat by external factors-particularly QOF, and we will have to concentrate our efforts to preserve it in its natural form.
I can’t say that QOF has had no beneficial effects for patients-I think that it has and has probably helped to improve some aspects of our care, and highlight some deficiencies as well. However, it is a blunt tool, and it was never designed with the consultation in mind.
I don’t like QOF now. In fact I resent it. Moving goalposts and adjustments year on year soak up efforts and resources from the practice that should be focussed on patient care. I dread to think how many hours we put aside to discuss QOF targets/exemptions and how many staff we have working on this. The practice machine works away slowly at this over the year-but the focus is never really on good outcomes for the patient, it is on the financial implications for the practice.
Let’s go back to Mr Jones. Our first thoughts are to try to engage with him and untangle his problems. Depression? Migraine? Bereavement? In to which domain, if any, will he be categorised by QOF? When I am trying to help a patient with possible depression, I don’t want to be trying to remember which template to complete, or whether I have remembered every component of said template. I want to be listening, watching. I was glad to see the passing of PHQ9-some found it helpful but I cannot remember it ever helping in a treatment decision. Why did we do PHQs? Why do we spend time completing templates? For patient care? I’m not convinced. If our primary interest is patients, then QOF=finance= possible conflict of interest.
So where to next? Are we, as physicians, able to manage and treat patients without being contaminated by financial or practice affairs, and is this a reasonable expectation? I hope that we are, but I don’t think that QOF helps us. We should look for alternatives, and pursue these in any future “negotiations” with DOH. I am not naïve enough to believe we can ignore the financial constraints within the NHS. I do believe, however, that we need to minimise the impact of this during the consultation.