The QOF, NICE, and depression

In his defence of the depression parts of the QOF, Alan Cohen also unwittingly illustrates some of the problems of the whole process.¹ For instance, when he states that patients like the use of questionnaires, it is because ‘they feel as though their symptoms are being taken seriously’, not because he can quote more substantive evidence that it makes a difference to harder outcomes. Too much concentration on process and not outcomes. Note that Dr Cohen is not claiming GPs are taking the symptoms more seriously; the implication is that the designers of the QOF would favour the quick, somewhat superficial, and very impersonal patient health questionnaire (PHQ) over serious engagement between GPs and their patients’ personal concerns. Not only de-professionalising, as Toop pointed out in his editorial,² but very destructively reducing all patients from individuals with their own contexts and concerns to units in a production line.

Then there is the encouragement to over-reliance on the PHQ. This has been consistently shown to overestimate severe depression when compared with other measures. The widespread and uncritical use of the PHQ may be leading to over-diagnosis of depression with excessive antidepressant prescribing. Those responsible for the workings of the QOF need to be reminded constantly that all medical interventions capable of doing good can also do harm.

However, it is the statement that ‘Not to have incentivised GPs to identify a group of people who were more at risk clinically … would have been negligent’ that is truly outrageous. Here there are QOF points for applying a universal method that also has substantial error rates, with the possibility again that this will lead to over and under identification. Dr Cohen here has subscribed to the suggestion both damaging and now proved to be erroneous, that GPs will only take action that is financially rewarded. If the lie were correct, then what is the implication for all those other patients with long-term disabling conditions, also at higher risk of depression? Or is he suggesting that this QOF provision should be extended to all patients? In which case it would become, effectively, a screening programme for which, again as Toop points out, there is no convincing evidence.²

The QOF approach began as a limited set of targets to encourage more universal application of a number of measures that were backed by sound evidence and generally accepted as both achievable and beneficial. It has gradually expanded to incorporate more dubious measures that command less acceptance, and looks more and more like a set of hoops to make recalcitrant GPs work harder with little extra gain for patients. Meanwhile, the clamour from numerous lobby groups for inclusion of their pet measures in the QOF continues to grow. Not only de-professionalising, but very depressing and sadly, all too predictable.