The paper by Leydon et al illustrates the continuing tension between two important elements of generalism: the biotechnical (use of the measures PHQ9 or HAD-D introduced as part of QOF) that the authors refer to as ‘hard technology’, and the biographical (a narrative-based approach to diagnosis, based on the patient's context) referred to as ‘soft technology’.
Concern about the current extent of the contractual focus on QOF, and its potential to undermine the strength and complexity of the doctor–patient relationship, that supports quality at a deeper level, was one of the drivers behind the ‘Essence of General Practice’ project led by RCGP Scotland. This concern is confirmed by Leydon and colleagues in their paper when they suggest that, in some cases, the use of these tools causes dissonance within the consultation and may in some way ‘trivialise’ the consultation. However, the article also provides some reassurance that the evidence-based debate on the merits and problems associated with some of the elements of QOF continues.
However, the central issue is this: in an evidence-based world, we should look for evidence of improvement of quality as a result of the introduction of a new instrument designed to measure performance. Is there evidence that the diagnosis and management of the complex set of conditions that are labelled as ‘depression’ has been improved by mandating the use of these tools in everyday general practice?
The authors end by quoting the excellent work done by Trish Greenhalgh where she suggests that we need to open up the ‘black box’ of clinical experience and judgement and how they interact with evidence. We concur with their suggestions that in the future, more piloting, more engagement with practitioners, and a more measured response to the difficulties caused by and pertaining to measurement would be helpful for patients and GPs alike.
- © British Journal of General Practice, May 2011