The QOF's shift away from process indicators is probably unstoppable, but the GPC must resist attempts to include hard outcomes
It's possible NICE may be regretting the day it was given the honour of reshaping the QOF. Ever since then, and particularly since the new Government was elected, it has been under pressure to overhaul the system to base it more heavily on outcome measures – a move that many GPs oppose.
Professor Helen Lester, the GP academic responsible for piloting new indicators for NICE, has herself pointed out the problems with using hard outcomes – not only are there insufficient heart attacks and premature deaths each year to provide a countable measure of quality of care, but there are so many other inputs into a patient's health than the 10 minutes every few months they spend with a GP. Outcome measures would hold GPs to account for influences outside their control.
The institute last week unveiled its attempt at a compromise, designed to look sufficiently like an outcome-based framework to get ministerial sign-off, but taking into account enough of GPs' reservations to avoid a revolt.
It has proposed introducing tight packages of targets, still based around an intermediate outcome, but surrounded by process measures defining care so precisely that a benefit for outcomes could be assumed. Take hypertension – GPs would earn points if they met a blood pressure target, or treated patients with three antihypertensives, or took one of a series of measures to intensify treatment within 90 days. It's a framework for robots, who agree not only to be assessed against clinical targets, but also on exactly how they are achieved. And while GPs may accept the idea, if it means dodging the bullet of true outcome targets, they're unlikely to be thrilled by accompanying plans to increase the lower or upper indicator thresholds – or both.
GPs responsible for developing the ideas seemed nervous about how they would be received. The LMCs conference has, after all, provided a sceptical verdict on the value even of the existing QOF. LMCs did reject a motion criticising it for causing polypharmacy, but backed another warning it caused iatrogenic diseases such as falls. The conference also highlighted a glaring inconsistency in UK health policy – the simultaneous pressure on GPs to diagnose more chronic disease and treat it more intensively, while reducing referrals and avoiding high-cost drugs. It is hard to see how QOF indicators defining a minimum number of blood pressure drugs would ease that inconsistency, particularly if put alongside the new quality and productivity indicators.
The QOF's shift away from process indicators is probably unstoppable, but the GPC must resist attempts to include hard outcomes or to burden intermediate measures with new bureaucratic complexity. And GP negotiators must launch a fight-back – they should only accept toughening of targets if accompanied by clear exclusion criteria, to avoid practices chasing pointless points in elderly patients who may not benefit. Is it time for a QOF age cap?
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