Copperfield pens a diary entry on his nemesis: the new QOF guidance
I knew my quality and outcome framework obsession had reached pathological levels when my wife started greeting me with, ‘Bad day at the Qoffice, dear?’ But if you thought this QOF year was tough, wait until the next. Because the latest iteration shifts huge points/prizes to the CV section while raising the upper thresholds to ‘unattainable’ and insisting we try every lipid lowerer in the BNF.
So here’s a sneak preview of my diary next year:
March 14, 2026. I cannot believe it. I’m utterly devastated. This is just awful.
It was only a week ago that I saw him in the late night LDL clinic. We’re still stuck at 49.8% for the big bucks chol 004. That’s despite our strategies to raise awareness: the ‘Every LDL helps!’ badges for staff, the Dalek screaming ‘Exstatinate’ in the waiting room and me doing the London Marathon dressed as a chylomicron.
So there I was with Mr Smith. My last throw of the QOF dice. His LDL remains 2.001 despite being on a kilogram of atorva, plus bolt-ons, plus repeated bloods hoping lab variation might nudge it down.
I explain his cholesterol level remains high. He asks if being 0.001 above target is that important, but then he’s not qualified to have an opinion, is he? As I point out.
I scroll the NICE guidance, find a drug I’ve never heard of and suggest it to him.
‘So will this help?’ he asks. I think this through. It’ll be beneficial in a broad, evidence-based, public health way, but to the individual it’s highly unlikely to make much difference aside from medicalising him forever, which means the person most likely to benefit is me. So I explain these complex issues and nuances in patient-friendly language.
‘Yes,’ I say.
‘But doctor,’ he protests, ‘I’ve already tried everything. All the pills. The weight loss. The exercise, no dairy, no treats, no booze. Life’s miserable. I get so low sometimes that…’
I notice him welling up and I remember I am a doctor rather than a number cruncher.
‘Mr Smith, I believe you may be depressed.’ I sit back and make meaningful eye contact for the first time. ‘Think how much happier you’ll be with a normalised LDL.’
Reluctantly he agrees and leaves with a prescription and another blood form.
And now this. A notification of death. Hit by a bus while walking home in the dark from our appointment. Just awful. What a tragic waste. Yes, he’s come off the denominator but that only shifts us to 49.9%. All that time and effort for nothing.
I redo the maths. Subtracting one more would do the trick. I call reception.
‘Can you get an urgent appointment for Mrs Jones in the late night LDL clinic? Tell her I’ve thought of another approach to her cholesterol.’ I smile. ‘And can you give her as late an appointment as possible?’
Dr Tony Copperfield is a GP in Essex
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Very, very funny. I hope you are working on a satirical novel about the NHS – we’ve got to laugh or else ………..
as satisfaction with GP and ability to get an appointment with symptoms continues to fall we continue to agree to a contract that extends prevention and fills more and more appointments.
How about no extension of prevention till the workforce expansion has consolidated enough to see poorly people in an acceptably quick timescale with a GP they know
Declined lipid lowering therapy…..more beautiful than the word tariff
Great blog – I want to read the book full of these as well
Lipid lowering madness – all on the erroneous extrapolation of the supposed (minimal/debatable) benefits of statins being due to their effect on LDL (rather than their pleomorphic effects), when actual evidence shows that purely lowering LDL (e.g. with ezetimibe/PCSK9/inclisiran/bempedoic etc) has no clinical benefit – trial data massaged by using surrogate and composite endpoints to try and demonstrate significance. Absurd massive squandering of NHS resources.