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Has QOF resulted in quality care or just tick-box medicine?

The quality and outcomes framework (QOF) is the biggest experiment in delivering quality health care in the world. But has it really delivered quality or are

GPs just ticking the right boxes? In this e-mail debate Dr Helen Lester, leader of the QOF expert review panel, defends the framework while Dr Eugene Hughes, founder of the Primary Care Diabetes Society, says it is actually lowering quality as GPs have no incentive to aim beyond unambitious targets

Dear Helen,

A leading expert on diabetes has called QOF 'the greatest primary care experiment the world has ever seen', pointing out that in no other health care system have family doctors and their teams been expected to reach the metabolic indicators which were put forward, together with the process measures involved.

It would appear the experiment has been a success, in that most practices seem to have averaged 1,000 points, and probably 80-90 points for diabetes.

The cynical view might be that if you dangle a pot of money in front of the eyes of GPs, they will do all in their power to get their hands on it. Do you feel the 'achievement' of points and indicators in diabetes will represent real change in metabolic control?

Furthermore, will it have any impact on cardiovascular outcomes? Does exception reporting disadvantage those at greatest need ­ the defaulters, the poorly controlled, the elderly?

And finally, on a philosophical note, does this represent a triumph of payment-led, box-ticking medicine over an altruistic, evidence-based, patient-centred approach that may have failed our patients in the past?

I have yet to be convinced that we are heading down the right path. Our practice achieved 96 points for diabetes, but morale has suffered.

Best wishes,

Eugene

Dear Eugene

Thanks for your e-mail. Frankly at the moment I don't know whether the points and indicators in diabetes will represent a real change in metabolic control.

To some extent your question and query about exception reporting will be addressed by the analysis of the first year's QMAS data. But if you want my evidence-based gut instinct, then yes, I do think that incentivising GPs to record and reduce HbA1C and refer patients for retinal screening encourages improvements in the structure and process within primary care that ought to translate to better metabolic outcomes and fewer longer-term complications for patients. Epidemiological analysis from UKPDS certainly suggests a positive exponential relationship between increasing HbA1C and the absolute risk of complications.

As far as your philosophical point is concerned, I have real difficulty with the view that somehow paying GPs for doing specific types of work that includes ticking their computerised templates means that we have become mechanistic droids who see pound signs over our patients' heads as they walk in the door.

It is possible to tick a box and look your patient in the eye, to embrace an evidence-based QOF and still be patient-centred. Sure, it adds time to the consultation but as long as I have been a doctor, there has never been 'enough' time. We have 47 minutes for each of our patients each year and we don't have to tick every box in one consultation. I also think the IT side will become easier as we get used to and internalise the indicators.

As far as practice morale is concerned, well we had our ups and downs, with something of a Dunkirk spirit about the place in the days preceding our QOF visit, but as a team we feel the contract and particularly the QOF have helped us to improve the care of our very deprived patient group.

Indeed I think it's the area of health inequalities where changes to the way we work will have most effect.

With best wishes

Helen

Dear Helen,

In the early days of the contract, I travelled around the country telling people what a shambles it was, particularly the QOF. I have had to eat a good deal of humble pie since then.

Throughout the past year I have seen tremendous industry in practices, as they have sought to clean up registers and record data. My early fears that exception reporting would be widely abused seem to have been allayed.

However, I still think the system is heavy on process and light on outcome. In an article in Pulse earlier this year I compared two practices ­ one excellent at recording but poor at effecting change, while the other comprehensively addressed metabolic control.

The difference in reward was just three points (see box, page 29). And so we accept this imperfect instrument, but set about improving it. Some minor changes may be needed to existing indicators, but there are legions of interest groups stating their case for inclusion ­ dermatology, obesity, mild depression, eating disorders.

I worry whether we will be driven towards a system where there are 3,000 QOF points, profit- and protocol-driven mentality, and franchised care ­ is this what we signed up for?

With best wishes,

Eugene

Dear Eugene

I think your worry about the current framework being more focused on process than outcome is an inevitable part of the evolutionary process of achieving better long-term outcomes for our patients.

You're also quite right that a number of interest groups have submitted evidence to the expert panel. However, QOF represents less than 20 per cent of the total new contract income and many of these areas will be ably and indeed perhaps better addressed through the enhanced services mechanism. So, no, I don't envisage a 3,000 point QOF in 2006!

I think your key point is the fear of franchised care. This issue strikes at the heart of the matter for many GPs, who envisage a nightmare future of centrally managed McPractices. However, my fervent belief is that more managed care can be an effective way of addressing aspects of the inverse care law through financial incentives to provide better quality (often protocolised) care.

There is certainly some evidence to suggest GPs changed their behaviours to meet centrally driven financially linked targets for cervical screening in the 1990s, and that this helped to narrow inequalities in the coverage of cervical screening between affluent and deprived areas.

There is, of course, an inherent tension in trying to use the QOF to provide first-class care for the 'masses' levelling up, if you like, the general standard of UK primary care, and striving to achieve the best for individual patients.

This ability to oscillate our gaze from the general needs of a community to the particular needs of the person in front of us will be challenging. But it is also vital if we want to guard against a future of faceless mechanistic primary care.

With best wishes

Helen

Dear Helen,

It was interesting to hear you talk of McPractices ­ for I believe there are mounting concerns about deprofessionalisation. We are in an environment where many groups are challenging the traditional territory of general practice. We now have nurse prescribing, an increasing role for pharmacists, the potential to use US-style 'health assistants' with two years' postgraduate training, and even NHS Direct proposing to undertake medication reviews in chronic illness.

There is also clearly an agenda for increasing privatisation of health care, with the recent scare story that firms tendering to build health centres could also provide the health care under a Government scheme, and that PCT funds could be ringfenced to support this. It is no wonder that fears of franchised care abound ­ how close could we be to McDiabetes, for example, given the way the GMS contract has wrapped the care package in a (recyclable) polystyrene box?

I know many of my colleagues are hoping for an incremental approach ­ a cosmetic tweaking of some old indicators, a sprinkling of new ones, rather than a radical overhaul of the system. Primary care has taken a battering from the Maoist 'constant revolution' that has typified health policy since the 1980s.

We need time to pause, reflect and work out how we can reintroduce the rather faded concepts of patient empowerment and individual care plans to the New Order ­ if not, I fear we will lose our souls.

With best wishes,

Eugene

Dear Eugene

A wiser person than me once described the NHS as a place with more visions than Mother Teresa and more pilots than BA...I heartily agree with you that the review of the Q0F needs to be a process of evolution rather than revolution and that as a profession we need time to reflect on how we can help to ensure changes are for the good of the patient and the population.

I don't, however, agree with your concerns about deprofessionalisation. The 750,000 people who come through the doors of primary care each day want to be recognised, appreciated and understood. The vulnerable, the socially excluded and those with chronic illness in particular also want continuity of care.

The notion that this can only be provided by a GP is heavily influenced by historical precedent and fear of losing our traditional power base.

Continuity of care does not necessarily have to be provided by someone who went to medical school. Appropriately trained professionals allied to medicine can, and I believe should, be encouraged to share or take over some aspects of what we have traditionally thought of as the GP's role and may well improve the efficiency and the effectiveness of care.

I do, however, share your concerns about the increasing privatisation of the NHS. Under the new contract, if GPs choose not to provide additional or enhanced services, these could theoretically be provided by the private sector, undermining Aneurin Bevan's vision of universal health care as a right, not a commodity to be bought nor sold.

In the brave new world of nGMS, perhaps we should worry less about losing our souls and concentrate more on recognising when and why we are supping with the devil?

Eugene, it's been a pleasure

Best wishes

Helen

How the quality framework rewards process more than outcome

Practice 1: excellent at recording, but poor at effecting change. It has recorded data on all its diabetic patients, showing:

·100% have a BMI >30

·100% are smokers and have been told to stop ­ but haven't

·100% have a BP >140/85mmHg

·100% have a total cholesterol >5mmol/l

·100% have HbA1C values >7.4 but <10 per="">

·100% have a record of absent peripheral pulses

·100% have a record of abnormal neurological findings

·100% have abnormal creatinine and microalbumin levels, but none are on ACE inhibitor

The practice opts to take no action. It has achieved 49 points ­ almost 50 per cent of the total for diabetes ­ but it is not providing quality care

Practice 2: comprehensively addresses metabolic control. It has:

·Reduced the average BMI of all patients from 30 to 25

·Stopped all patients smoking

·Reduced the average BP from 160/100 to 150/90mmHg

·Reduced average cholesterol values from 6 to 5.1mmol/l

·Referred all patients with at-risk feet for further evaluation

·Reduced the average HbA1c from 9 to 7.5 per cent

·Acted on abnormal microalbuminuria testing by appropriate prescribing of ACE inhibitor

This practice will achieve 52 points ­ just three more than practice 1

Helen Lester is a GP in Birmingham, QOF project lead of the expert review panel and reader in primary care, University of Birmingham

Eugene Hughes is a GP in the Isle of Wight, a founder of the Primary Care Diabetes Society, a member of Primary Care Diabetes Europe and editor of Diabetes and Primary Care Journal

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