The views contained in the editorial written by Professor Les Toop and Dee Mangin of the University of Otago, New Zealand, in the BJGP1 coincide to a very large degree with those of some of the Executive members of the National Association of Primary Care. That is: the very nature of professionalism, professional values, and the concept of good care (as understood in GP training) are being corroded by the GP contract's Quality and Outcomes Framework, as is the patient-centred ethos of general practice.
The article draws attention to Downie's description of the characteristics of a profession that underpin good care: a credible profession must be independent of the influence of state or commerce; disciplined by its own professional body; have claim to and be actively expanding its unique knowledge base; and concerned with the education of its members.2 It is clear that as a result of the introduction of the GP contract, the first criterion has been swept aside, maybe unwittingly. With the requirement that from 1 August 2007 all those who wish to become a GP principal must undertake the MRCGP examination, there is hope that the second and fourth criteria will in time be universally met. Revalidation should address any failure in relation to the third criterion.
It is unfortunate that many practices failed to keep detailed clinical patient data, and it is this failure into which the QOF has made some serious inroads, but information which is merely used for accountability purposes and is not actively used as knowledge to inform and improve patient care, both for individuals and wider populations, is equally meaningless. There are opportunities to convert this information into knowledge about patients' health and wellbeing, and to assess the impact of interventions to measure outcomes. The profession itself should be driving this and should be seeking to select targets based on local need. What the QOF has yielded to date should be used positively by the professionals themselves, as well as at PCT level and nationally, to understand the value of interventions and trends in disease. Where is the wisdom of leaving such powerful information untapped on individual clinical systems?
Equally, we agree that damage has already been done in alowing greater status to be given to what is written and coded than to what is spoken in the patient–doctor relationship. The greatest challenge facing medicine today, as the article says, is for it to retain or regain its humanity, without losing its foundation in science. Medicine by numbers completely undermines the humanity of its delivery.
One of the possible ways through is for the profession's leaders to negotiate the alternative approach advocated in the article. Let us hope they can do so.
- © British Journal of General Practice, 2007.
