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Should GPs support local QOFs?

Local QOFs, with indicators differing not just at PCT level but between practices, are essential to tackle hugely varying needs, argues Professor Chris Drinkwater of the NHS Alliance. But the GPC's Dr Richard Vautrey warns local QOFs would take money from evidence-based national quality indicators and use it to fund local priorities that are often determined on a whim

Local QOFs, with indicators differing not just at PCT level but between practices, are essential to tackle hugely varying needs, argues Professor Chris Drinkwater of the NHS Alliance. But the GPC's Dr Richard Vautrey warns local QOFs would take money from evidence-based national quality indicators and use it to fund local priorities that are often determined on a whim



When the NHS Alliance responded to the Department of Health's consultation on the future of the QOF, we recommended that up to 20% of indicators should be determined locally, by PCTs and GP practices agreeing local indicators selected from a nationally approved menu.

There are two main arguments against such proposals for local QOFs - first that the plan would create a postcode lottery and second that it would have significant implications for the UK basis of the GP contract. But arguments about a postcode lottery in healthcare always seem to ignore the fact that we already have one, both in terms of outcomes and demand for care. The former health secretary John Reid, announcing spearhead PCTs to tackle inequalities in health, famously noted that life expectancy decreased by one year for each of the eight tube stops between Westminster and Canning Town.

Different PCTs have different needs and demands. There is significant variation in terms of age, ethnic mix and population turnover between Tower Hamlets and rural Devon, and between Bradford and rural Northumberland.

Yet this large-area variation also hides even more significant local variation, particularly at practice level. At the most extreme end of such local variation, some practices have significant numbers of patients for whom English is not the first language, and at others people aged over 60 may represent as much as 30% of the population. Yes, some of this should be addressed through local enhanced services, but these services would be strengthened if their outcomes could be measured by local QOFs, using approved national indicators. This approach would also allow comparison and development of best practice between Tower Hamlets and Bradford and rural Devon and Northumberland.

The QOF consultation is also explicitly proposing a move towards the measurement of outcomes, rather than processes. This will mean a greater focus on indicators such as CKD03 (the percentage of patients on the chronic kidney disease register in whom the last blood pressure reading measured in the previous 15 months was 140/85mmHg or less) at the expense of process measures such as SMOKE01 (recording smoking status).

This approach is already proving challenging as exception reporting statistics from the Information Centre for 2006/7 show us. The exception rate for CKD03 was 29.7%, compared with an exception rate of 0.48% for SMOKE01.

Professor Helen Lester and Professor Azeem Majeed1 have suggested in the BMJ that because outcomes are related to the social demographic characteristics of the population (rather than to the primary care they receive), an increasing emphasis on them could create perverse incentives for practices in disadvantaged areas to exempt sicker patients or those with more complicated problems.

In our consultation response, the NHS Alliance suggested that it was therefore worth exploring the feasibility of developing indicators that could be adjusted for patient characteristics such as comorbidity, disease severity and socioeconomic status. This suggestion would inevitably result in greater variation of the QOF at local level but it might well help to address inequalities.

The 2007 DH review of health inequalities demonstrated that although the health of the total population had improved, the gap between the best and the worst had increased. Similarly, the QOF has improved the health of the total population - but this probably still hides unacceptable variation between the best and the worst. This needs to be addressed and is best addressed at local level. But the 20% of locally determined QOF points should be subject to stringent review. I do not believe that this will result in a postcode lottery, but rather a fairer allocation of resources.

Professor Chris Drinkwater is president and public health lead of the NHS Alliance and a former GP



For all the rhetoric of local control and decision-making, primary care organisations know only too well that there is very little freedom to step outside the plethora of targets and must-dos coming from the Department of Health via the increasingly powerful SHAs.

So given the chance to have greater control over how the QOF is funded and its targets set, it is no surprise that PCOs have said a collective 'yes please' and 'give us as much control as possible'. If they had their way, PCOs would like to set the whole QOF and have full control over its funding.

Why, then, is this bad news - and why have the GPC, RCGP and many others opposed local QOFs?

First we have to ask what clinical area is currently in the QOF that some PCOs could say is not a priority for them? The idea that there is a big enough difference in patterns of heart disease, hypertension, diabetes or mental illness between neighbouring PCOs to warrant different priorities is not supported by the facts.

Before the last reorganisation, when PCTs were smaller, they all had various local initiatives described in health improvement plans. What did they achieve apart from generating countless meetings and documents? I suspect very little.

The reality is that local priorities are set by a small number of individuals with their own special interests. A strong local voice can drown out all others. The reason why one PCO chooses a focus on sexual health while another chooses mental health often bears little relation to robust evidence of their relative health needs.

The big risk of a local QOF is that we would end up with postcode healthcare where priorities are completely different depending on where you happen to live. If you happen to live on a boundary between PCTs and miss out on treatment, well, that's just bad luck. It would widen health inequalities, not address them. It would also signal the end of a truly UK contract.

The QOF is one of the great success stories of this Government because it is actually reducing health inequalities. Whether you live in Dundee or Durham, Carlisle or Cardiff, you can be sure your GP will be working to the same standards when it comes to managing the key long-term conditions.

The QOF has narrowed the once-yawning gap between the care offered by the best and worst practices. Patients can now expect to get good quality care at any practice they register with, and everyone can see how one practice's standards compare with another, even one at the other end of the country. This would all be lost with the variation and fragmentation that would occur with local QOFs.

The standards in the QOF have been accepted by practices because the evidence for primary care interventions in these areas is solid. But the evidence is no different between English regions, nor even across the four nations.

Much clinical evidence is applicable internationally and it is for this reason that the QOF has been so successful. It is based on a solid foundation. If the evidence exists that an intervention in general practice in an important clinical area can make a difference to the lives of patients across the UK, why should a local medical director or PCO chief executive be able to go against that evidence and prioritise other areas?

Local priorities should instead be tackled using LESs, which were designed exactly for this purpose. There is no need to raid QOF funding to develop LESs. They should be commissioned with additional local funds and can be tailored for local needs. They should not, however, fight for priority and funding with the most important clinical areas affecting patients right across the UK.

Dr Richard Vautrey is deputy chair of the GPC and a GP in Leeds

Should GPs support local QOFs? yes No

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