Patients will not remember you for how well you achieved your measurable performance indicators

Simon Tobin retired from clinical work in March 2026 after 33 years as a partner in the same practice. He continues to work as a GP appraiser and with the fellowship team at the RCGP

After retiring, I found myself wondering how my patients — many of whom I had known for over three decades — might remember me.
Unsurprisingly, none of my retirement cards thanked me for adhering to guidelines or achieving Quality Outcomes Framework (QOF) targets. Instead, many said they were grateful for my kindness, continuity and the reassurance of being known and listened to during difficult periods of their lives. I believe that modern general practice has become so focused on targets and guideline adherence that we risk losing sight of what matters most to patients.

The term ‘guideline’ originally referred to a rope or cord used to help people traverse difficult terrain. However, the safest route is not always the one that the patient wishes to take. Many prioritise autonomy, dignity, quality of life or freedom from medication over maximal risk reduction.

I worry that guidelines are increasingly regarded as tramlines from which we must not deviate. Rigid adherence shifts care towards interventions and prescribing, and away from where it should really be — on the patient’s priorities, preferences and values. Our systems increasingly remunerate doctors for managing diseases rather than caring for people. Illness is experienced as disruption, anxiety, pain, uncertainty and dependency but healthcare systems often reduce illness to surrogate markers and targets. Why aren’t we rewarding listening, or kindness or caring? Continuity of care is associated with fewer hospital admissions, greater patient satisfaction and even reduced mortality¹ yet none of these outcomes has ever been incentivised through QOF

David Sackett defined the pillars of evidence-based practice as the ‘…integration of best research evidence with clinical expertise and patient values.’² It is the individual’s preferences and priorities that become hard to see when we hyperfocus on targets. The problem is not evidence-based medicine. It is the gradual transformation of evidence into protocols, and protocols into performance management. Sackett’s third pillar has collapsed.

Tight control of blood pressure may make sense epidemiologically, but not necessarily for the person sitting in front of us. The trade-offs may include light-headedness, swollen ankles, polypharmacy and the creeping burden of medicalisation. They might be far more concerned about arthritis limiting their mobility or their struggle to manage the distress caused by their spouse’s worsening dementia. We often ask people to accept immediate burdens — extra tablets, side effects, appointments and anxiety — for personal benefits that are unlikely, delayed and uncertain.

Our expanding ability to measure disease markers creates a temptation to confuse measurable abnormalities with patient priorities. Modern healthcare increasingly favours what can be counted over what truly counts.

My patients consistently told me that what they valued most was continuity, kindness and feeling listened to. They wanted doctors who knew them, understood the context of their lives and helped them navigate illness in ways consistent with what mattered most to them. These qualities may be harder to measure, but they matter deeply to patients. If we are serious about improving the lives of our patients, we need to rediscover the wisdom of Prof David Haslam’s often quoted³ but simple advice: “Shut up, listen, care and know something.”

References:

1. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018 Jun 28;8(6):e021161. doi: 10.1136/bmjopen-2017-021161
2. Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000.
3. Papanikitas A. Shut up and listen! Br J Gen Pract. 2022 Jan 27;72(715):69.doi: 10.3399/bjgp22X718349

Featured Photo by Ioana Cristiana on Unsplash