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A faulty production line

Exception reporting is no game

The Government is to review the rules of exception reporting over fresh 'gaming' accusations - but is that punishing the whole class for the misdeeds of the naughty kids at the back?

The Government is to review the rules of exception reporting over fresh 'gaming' accusations - but is that punishing the whole class for the misdeeds of the naughty kids at the back?

Exception reporting is a bland term for an activity that provokes some pretty fiery debate. It was designed to protect individual patients from the rigid demands of the QOF and GPs' income from factors outside their control. But it is viewed by NHS managers as a get-out-of-jail card for practices that aren't going to hit their targets. The Government too has been suspicious of GPs' use of exception reporting almost from the start.

As long ago as December 2005, ministers were declaring their intention to clamp down on what they saw as abuses of the system.

It wasn't long before ‘QOF gaming' joined the GP lexicon alongside Read codes and the MPIG. Some PCTs have even resorted to fraud investigations against practices with the highest exception-reporting rates.

Against that backdrop, the Government's latest pledge to reform the system, by forcing NHS Employers and the GPC together for talks, hardly comes as a surprise. Nor is distrust of the system confined to PCO chief executives and Government ministers. Many GPs have also cast suspicious glances at their neighbours as local figures have revealed wide variations in rates. The GPC must be tempted to give some ground during its talks with the employers, rather than expend valuable political capital defending an unpopular system. But before negotiators give in to that temptation, they would do well to take a look at the available evidence.

The National Primary Care Research and Development Centre has conducted two very good studies of exception reporting – good enough to earn publication by the prestigious New England Journal of Medicine. The first,

in July 2006, provided impetus to many of the concerns over the system. It concluded exception reporting was ‘high in a small number of practices' and, although use of the system was ‘not extensive', it was the strongest predictor of QOF performance.

The Government's interest was piqued, but few ministers took heed of the key caveat – that ‘more research is needed to determine whether practices are excluding patients for sound clinical reasons'.

Heed should have been taken though, because after two years of further research, the same researchers reached rather different conclusions. This time, they assured us, ‘rates of exception reporting have generally been low, with little evidence of widespread gaming'. And they went further: ‘As a system for safeguarding against inappropriate treatment, exception reporting has substantial benefits: it is precise, increases acceptance of the programme by physicians and ameliorates perverse incentives to refuse care to difficult patients.'

So, exception reporting is good for us. The GPC has been adamant that when it comes to the QOF, what counts is the evidence.

It must stay true to its word, and not agree to changes that might unfairly penalise practices and subject patients to unnecessarily aggressive treatment. The many must not be punished for the actions of a very few.


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