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A local QOF for local problems?

There's fierce debate between GP about the merits of local variations on the quality framework

There's fierce debate between GP about the merits of local variations on the quality framework

There's no doubt that different areas of the country face very different challenges in the provision of healthcare.

But there is considerable doubt over how to shape policy to take into account such regional variation, and the Government's plans for local versions of the quality and outcomes framework have prompted fierce debate.

'It would be an absolute nightmare,' says Dr Stewart Findlay, a GP in Bishop Auckland and former PEC chair of Durham Dales PCT. 'The PCTs would be incapable of sorting out the IT issues needed to support it and we could end up with a postcode lottery.'

The Department of Health introduced the concept of localising elements of the QOF in its submission to the Health Select Committee's inquiry into workforce planning earlier this month. The submission, reported in last week's Pulse, said: 'As part of the ongoing development of the QOF, the Government wishes to explore the scope for further flexibility for local commissioners to address local issues.'

Alastair Henderson, deputy director of NHS Employers, says: 'There are no detailed plans at the moment. We are at the start of a wider debate on healthcare delivery; on getting the benefits of local flexibility with a national framework. There is a move to more local flexibility and we believe this is the right direction.'

Theory vs reality

In theory, most medical professionals would agree that addressing local health inequalities, potentially via the QOF, is appealing. Sandra Gidley MP, a Liberal Democrat health spokesperson and member of the Health Select Committee, says: 'Anything that is adaptable to local needs has to be looked on as quite favourable. The flexibility is to be welcomed.'

Dr Harry Yoxall, a GP in Somerset and secretary of Somerset LMC, agrees. 'I understand that the health needs are not the same in my local rural Wessex community as they are in a city in the North-East. I see where they are coming from.' However, both Dr Yoxall and Ms Gidley are among those voicing concern that, although a local QOF could work in theory, it could be a totally different beast when unleashed in reality. Dr Yoxall says: 'The similarities around the country are greater than the differences and we should all be working to the same national standards.' Ms Gidley adds: 'It must be underpinned by a national minimum standards system. There must be basics, with the option for flexibility on top of that.'

Dr David Jenner, NHS Alliance contract lead, says: 'I think a lot of commissioners would like to do things locally. But the practicalities and feasibilities must not be ignored.' He suggests several mechanisms to ensure this happens, such as 50 of the 1,000 QOF points being set aside for local targets (see box below).

General scepticism over the possibility of moving the QOF to a local framework stems from a widespread mistrust of PCTs and a lack of belief that the infrastructure would be in place. Dr Gary Calver, a GP in Kent who was involved with the original pilot for the QOF, the Primary Care Clinical Effectiveness Project (PRICCE) in 1998, says: 'I'm apprehensive about a local QOF because PCTs are still struggling to come to terms with their reorganisation. I think they lack the imagination that the PRICCE pioneers had to improve quality of care – their ethos is about shillings and pence as the pressure on them from the Government is purely financial.'

He adds: 'It could improve the QOF – if it is done in the right way – but it needs centralised guidance otherwise it could become just another tool to screw general practice down.'

PCTs have tentatively welcomed the chance to have a local element in the QOF. Trevor Beswick, associate director of commissioning at Bristol PCT, says: 'The ability to negotiate some of the QOF locally could be useful. It would allow us to address local health inequalities and priorities.' However, even he admits that there would have to be a major rethink of the national infrastructure before this could happen. 'What's great about the national QOF model is the infrastructure. This robust system would be needed at local level too. Perhaps local targets could be accommodated within the QMAS system,' he suggests.

Dr Laurence Buckman, deputy chair of the GPC, reckons local QOFs will never happen. 'There's no such thing as a local QOF. Whoever has suggested this doesn't know what the QOF is about,' he adds.

Dr Buckman says the most important issue was being ignored – that there are already means to deal with local health inequalities and priorities built into the contract through local enhanced services. NHS Employers' Mr Henderson responds: 'Nobody's saying there are no methods for local flexibility already. We know it's different in Newcastle to Newquay, that's why it's good to be having this debate.'

But Dr Buckman says: 'The QOF cannot be used as a tool for the Government to do what it wants. We must get away from this idea that the QOF is the only way to make things happen, because it's not.'.

How a local QOF might workHow a local QOF might work How a local QOF might work

Dr David Jenner, NHS Alliance contract lead suggests some ways that a local QOF could be negotiated:
• about 50 of the QOF's 1,000 points could be set aside for local targets
• local targets would have to be simple, such as obesity targets and chlamydia screening, and not based on complex screening or IT capability
• alternatively there could be a list of five to 10 optional extras to the nationally agreed QOF, which local trusts could choose from

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