Just how well is QOF delivering?
The quality and outcomes framework was launched in April 2004 as a visionary piece of health policy, destined to lead the world in using incentives to drive up standards.
Policy wonks from the US to Europe are standing by to assess its success at improving care for chronic diseases such as heart disease and diabetes.
But the scheme has come under increased scrutiny recently with a series of studies suggesting it may have failed to narrow health inequalities – and might 'crowd out' conditions which do not carry incentives.
So, just how well has the QOF delivered for patient care? Ministers are adamant it has been a success. Last week health minister Rosie Winterton praised 'good progress' in driving improvements in cholesterol control.
And a recent study, presented to the European Association for the Study of Diabetes conference, found the contract had brought 'sustained benefits' for diabetes patients.
Dr Colin Kenny, a member of the steering committee of the Primary Care Diabetes Society who has written a BMJ editorial on the QOF, agrees: 'It's delivered two things – real data on what's going on in diabetes and, second, real achievements.'
A good thing
Some GPs feel care has improved in line with or more than their pay. Dr Peter Harvey, a GP in Holt, Norfolk, says: 'The QOF has given us a framework on which we can build patient care.
'QOF covers conditions GPs spend most of their time with, so it's a good thing these were identified and incentivised.'
But last week Pulse revealed details of a new study showing anxiety and depression – which at the time did not carry incentives – had lost out in the chase for points elsewhere.
'Crowding out is a real concern to me and the research team,' says lead researcher Professor Bruce Guthrie, professor of primary care medicine at the University of Dundee.
'The contract measures certain aspects of care and it's intended practices focus on these, but the risk is that less attention is paid to other areas – practices get tunnel vision.'
There are three obvious solutions to the crowding out problem. One would be to do the unthinkable and dismantle the QOF – something none of the key players want.
A second option would simply be to incentivise more and more conditions, and many GPs now feel this is inevitable.
Dr Niall Finegan, a GP in Salford, Greater Manchester, says: 'The QOF is going to get more complicated and more will be added to it. There's no doubt they're going to load more into the QOF and more on to GPs.'
A New Labour third way might be to somehow incentivise holistic care, to ensure no areas of care are left out.
Professor Guthrie says: 'To some extent crowding out is inevitable, and the only change you can make to the contract is to ensure it is broad enough to cover important aspects. For example, the reason the 'patient experience' domain is in there and gets 100 points is to try to make sure the QOF isn't just about diseases in isolation.'
But Dr Tim Doran, research fellow in public health at the National Primary Care Research and Development Centre and a leading expert on the QOF, says holistic care points are more about performance across areas that are incentivised.
'Indicators are constantly being added but you can't incentivise everything. On the indicators we've looked at to date it does seem to have increased the rate of improvement of quality of care. The question then is do you think what's measured in the QOF is quality of care.'
For some GPs the problem runs deeper than merely what the targets are.
Dr Adam Pringle, a GP in Telford, Shropshire, says: 'As long as clinical care is driven by targets set by non-clinicians, none of whom have any grasp of clinical reality, then the targets will be inappropriate and have 'unforeseen' consequences. Un- foreseen as in could be predicted by a six-year-old.'