As the Government heads towards a new GP contract, the development - or abolition - of the QOF will weigh heavy on many GPs’ minds during the process. Ten years in, we have become accustomed to working with the QOF, but there’s still a lot that could be improved.
The push to include all of medicine in QOF should be resisted. The QOF is never going to cover more than a small proportion of consultations (albeit an important one), and my view is that the QOF should be smaller and account for a smaller proportion of GPs’ income.
The reason that it should account for a smaller proportion of income is to reduce its importance in the eyes of GPs and so reduce the unintended consequences of the framework. While it has undoubtedly led to improvements in processes of care, it’s far from a magic bullet for quality improvement. Guidelines, clinical audit, education and other approaches to quality improvement remain important and should not be forgotten.
Furthermore, the QOF has led to some aspects of care getting worse.¹ We showed this for some clinical conditions which were not incentivised, but the most obvious example is how the 48-hour target for appointments to see a GP led to booking systems that perversely made it more difficult for patients make appointments, especially with the doctor of their choice.
Support common practice
So let’s make the QOF smaller, and have GPs’ income made up from other sources. Let’s also be more careful about the selection of indicators. While the original QOF was controversial, there wasn’t that much criticism of the original set of indicators. This is because these were ‘low hanging fruit’ - things that GPs by and large thought they ought to be doing, and mostly were. Since then we have had a series of indicators introduced which sought to change what GPs thought was ‘good practice’ - the PHQ-9 indicator for depression is the best example - and other indicators where the evidence base was not that strong.
We should stick to indicators which are in line with widely accepted good clinical practice. Research shows that external incentives can damage professional motivation if they’re not in line with core professional values. We need to make sure this doesn’t happen with the QOF.
Promote continuity, and appropriate treatment
I’d like to incentivise continuity of care. This has declined in recent years for many reasons that GPs will understand well. While I understand that patients like continuity of care, I think it’s increasingly important for GPs. How else can we deal safely with an ageing population of patients who have an increasing number of complex problems in a 10 minute consultation?
However, continuity can only be incentivised with a very light touch - anything too numeric risks gaming. Despite the problems, I think we could incentivise ways of organising practices to promote continuity, such as those suggested by the RCGP.² We need to challenge the continued view of politicians that access matters and continuity doesn’t.
It’s also a mistake to increase the top thresholds too much, or at least to do so without expecting and allowing an increase in exception reporting. Exception reporting is a critical part of the QOF that helps GPs to ensure that their treatment remains relevant to the needs of their individual patients. There are plenty of people who would like to abolish exception reporting, but these calls need to be resisted otherwise we risk having a scheme that harms patients.
Overall, I’m in favour of the QOF. It’s right that GPs should get more income for providing better care, especially where that means increasing practice staffing levels and other expenses. The alternative (the old system) is that GPs who provided the best care took home less pay. That hardly seemed fair, though it’s of course still the case for GPs who choose to provide a high standard of care for small lists.
But GPs’ pay needs to be a balance of basic allowances, capitation and quality payments. Getting this balance right is something that health care systems in all countries struggle with. No other country has made as much as 25% of doctors’ income dependent on a ‘pay for performance’ scheme like the QOF, and we shouldn’t either.
Let’s use the opportunity of a new contract to maximise the gains we’ve made with the QOF - and minimise the harms.
Professor Martin Roland is Professor of Health Services Research at Cambridge University and a part time GP in Cambridge. He advised the government and BMA negotiating teams on the development of the original QOF from 2001 to 2003.
References
1 Doran T et al. The effect of financial incentives on incentivized and non-incentivized clinical activities. Evidence from the UK’s Quality and Outcomes Framework. BMJ 2011; 342: d3590.
2 Hill A, Freeman G. Promoting continuity of care. RCGP.
