Why was I not surprised last week to hear that talks between the BMA’s GP Committee and the government had broken down when the BMA had asked for GP targets to be relaxed, to free up time to deliver the extended the swine flu vaccination programme to children between the ages of 6 months and 5 years? Because the ‘targets’ in question are those set out in the Quality and Outcomes Framework (QOF) associated with the General Medical Services Contract. They are intended to deliver substantial financial rewards for what the government believes to be high-quality care.
Don’t misunderstand me. I have no quarrel with GPs, quite the reverse. The vast majority of them fulfil immensely complex and challenging roles with exemplary skill and dedication, and earn every penny they are paid. My quarrel is with the QOF itself, which offers the starkest example of the way in which target-setting and associated financial incentives can greatly disadvantage huge and clearly definable groups of patients, distort clinical priorities and drain primary care of flexibility.
I seethe with indignation when careless commentators announce blithely that hypertension is the commonest condition seen in general practice, as they often do. It is not. It may be the commonest condition included in the QOF, but it is knocked into a cocked hat by childhood eczema and kicked clean overboard by skin disease as a whole.
A recently published and well received dermatology Health Care Needs Assessment [1] found that skin conditions are the most frequent reason for people to consult their general practitioner with a new problem. Around 24% of the population in England and Wales (12.9 million people) visited their general practitioner with a skin problem in 2006, with the most common reasons being skin infection and eczema. It found also that of the nearly 13 million people presenting to GPs with a skin problem each year in England and Wales, around 6.1% (0.8 million) are referred for specialist advice.
The Assessment showed that the impairment of the quality of life of people with skin diseases such as psoriasis, atopic eczema and acne can be greater than for life-threatening conditions such as cancers; that the public view impaired skin appearance as being at least as important as disability or loss of function; and that skin disease frequently causes disability and loss of earnings.
There is also, of course, a clear determination by the government to remove a very substantial proportion of dermatology service provision from secondary to primary care.
So, presumably, the commonest skin disease are included in the QOF? Er…no, they are not – at all, in any form – and there is no longer any realistic expectation that they ever will be, which is disgraceful.
Going hand-in-hand with all this is an extraordinary paucity of dermatology training received by GPs and practice nurses. There is no compulsory requirement for dermatology training in undergraduate or postgraduate medical curricula. Typically, a medical student may expect to receive no more than about six days training in dermatology in his or her entire undergraduate and post-graduate education, and I have heard those six days referred to as “the derma-holiday”. The exclusion of skin diseases from the QOF can serve only to deter medical schools and their students from changing this bizarre state of affairs. “If they or we are not going to be paid for it, why bother to do it. Let’s concentrate on the things for which we will be reimbursed.” And who can blame them?
When determination to meet QOF targets overrides the need to vaccinate children against swine flu, the extent to which the QOF erodes flexibility becomes all too apparent. The fault is not with the doctors, who are constantly stretched, but with the competing demands of QOF targets on the one hand and transient priorities on the other. The damage being done to patient care by the QOF is clear . There has to be a better way of delivering equitable and properly prioritised primary care services.
Declaration of interests:
Peter Lapsley is patient editor of the BMJ. He was chief executive of the Skin Care Campaign for ten years until March 2007, is an Honorary Member of the British Association of Dermatologists, an Honorary Member and chairman of Trustees of the Primary Care Dermatology Society, and chairman of the Oversight Committee for the All Party Parliamentary Group on Skin.
1. Schofield J, Grindlay D and Williams H, Skin Conditions in the UK: a Health Care Needs Assessment, Centre of Evidence Based Dermatology, University of Nottingham, September 2009.