Tick boxes and templates are part of primary care; for better or worse, they look like they are here to stay. Recently in my clinic I had a patient booked in for a 10-minute consultation for a medication review. The review was for 16 different medications, for 10 different chronic diseases, and included the diabetes, coronary heart disease, heart failure, atrial fibrillation, hypertension, asthma, and rheumatoid arthritis templates to fill in, as well as the over-75 health check, admissions avoidance template, and the new local initiative, the polypharmacy template. The patient also had a new problem that they wanted to discuss. After all, a medication review just means the doctor ticks the box to say the patient can carry on getting their medication for the next year, doesn’t it? That only takes 2 minutes so there is plenty of time to discuss new dizziness as well, isn’t there? Ten minutes was never going to be enough for just the reviews needed. Thirty minutes later we had dealt with the dizziness problem (postural hypotension) and adjusted the medication, filled in the majority of the templates, and sorted out the prescriptions. I eventually had to let the patient go home, not least because there was a waiting room filling up with people waiting and getting impatient to see me. I asked the patient to return for review in a few weeks to re-check her blood pressure, knowing that we could complete the rest of the reviews then.
Overall I was satisfied that I had done what I could in the limited amount of time I had with a patient with complex multimorbidity needs while remaining patient centred and empathetic to the difficulties of living with multiple problems. There was more to be done, but I had prioritised the problems that mattered both to the patient and clinically. For some templates it was appropriate to wait until the next appointment. This was not a patient who was not going to come back and see us in the next year — their complex problems and ill health means that they are seen regularly.
Imagine my surprise then when I was asked by the practice to explain why I had not filled in every template during that 10-minute consultation. It is hard to justify why each box was not ticked. After all, a computer mouse tick takes less than a second. All 13 separate templates and each of their associated tick boxes could have been ticked within 10 minutes, but what would this actually mean? I can tick a box to say I have considered potential interactions of the 16 medications but did I just think, yep, everything looks OK, or did I ask the patient about symptoms to find potential problems? The tick box tells us nothing about good care. Being able to do all of the above in 10 minutes is still seen as quality care versus someone who takes longer and is more patient centred, but uses up more valuable resources. Templates are the interface of rhetoric and reality in terms of involving the patient in decisions about them and their care, and the paternalistic doctor ticking boxes because ‘he’ knows the patient best and therefore ‘he’ can tick the boxes without talking to the patient.
When there is little evidence that financial incentives and the templates they bring into the consultation have improved outcomes, why are we continuing to add more? Every specialty believes that their conditions are the most important and the least well managed in primary care and wants to add to QOF and the template culture. CCGs are adding their own local incentive schemes too.
The rewarding part of being a GP is to be a generalist — holistically looking at the patient in front of you and deciding what is the most important problem and what can wait. Completing templates and tick boxes for the sake of practice funding does not help improve GP morale or solve problems in recruitment. An excellent GP is not one who can tick boxes, but one who puts the patient at the centre of everything they do.
When are we going to hit reset on the tick boxes and templates, stop spending valuable time on things that do not benefit patients, and come up with innovative and creative ways to judge good-quality care?
- © British Journal of General Practice 2017