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Should QOF indicators be cycled on a rolling basis?

The QOF has to change to keep driving up quality and would become unwieldy if indicators were not moved out as well as in, argues Professor Helen Lester. But Dr Stephen Gardiner says a rolling QOF would simply lumber GPs with greater and greater workload for no new money, and would breach the terms of the contract

The QOF has to change to keep driving up quality and would become unwieldy if indicators were not moved out as well as in, argues Professor Helen Lester. But Dr Stephen Gardiner says a rolling QOF would simply lumber GPs with greater and greater workload for no new money, and would breach the terms of the contract

The QOF could be developed in a number of ways. The first and perhaps easiest option would simply be for the current indicators to be left unchanged, but this would have consequences for patient care and the wider health economy. We know that when the QOF spotlight is shone on an area, care improves above trend1. If no new areas are included, the potential benefits are limited to fewer conditions and therefore a smaller number of patients2. Since achievement has been generally high across the QOF, a static framework would also mean it becoming less cost-effective each year.

As another alternative, the QOF could be developed by adding new indicators to it on a regular basis, but without taking any of the old indicators out. However, this would lead, quite quickly, to the contract including a vast and unmanageable set of measures. One suggestion is to monitor across all these indicators but, rather than retiring old ones, only to pay GPs on an undisclosed subset. It's an interesting idea, but it would only encourage a grown-up version of 'spotting for exams'.

Overall then, the most sensible option is the one NICE appears to favour - that of removing measures from the QOF and replacing them with new evidence-based indicators in the same or new clinical areas.

Key factors

If NICE does decide to introduce a rolling QOF, there are at least three key factors that ought to be taken into account when deciding whether to retire an indicator: overall achievement, variation in achievement and exception reporting levels. For an indicator to be retired, overall achievement, in terms of the percentage of eligible patients for whom the target has been achieved, should be high. Variation in achievement rates between practices should be low, because retiring indicators with high variation could have adverse consequences for health inequalities. Exception reporting rates should generally be low or the reasons behind higher levels should be understood and agreed as valid.

There are some caveats here. One of the lessons of the first five years of the QOF is that there are almost always unintended consequences of well-meant change.

It is possible that if a rolling system is introduced, the profession will focus far more on the newly incentivised areas than retired indicators. Although some might argue that, for example, measuring blood pressure in someone with hypertension is core rather than quality general practice, there are only so many hours in a day and

if such as indicator were removed, a rolling QOF could inadvertently lead to a deterioration in aspects of patient care. This possibility makes it particularly important that the achievement levels of retired indicators are monitored and that thought needs to be given, ahead of time, about the most appropriate response if they fall.

Perhaps the most important thing about any move to change the way the QOF is developed is to make sure we keep having debates like this in the profession. Change is always challenging but if the process is transparent, the rationale is understood, the principles guiding indicator removal are agreed and safety guards are in place, a rolling QOF is the sensible way forward.

Professor Helen Lester is deputy director of the National Primary Care Research and Development Centre and a GP in Birmingham. She is the academic lead for the NICE-led QOF

In many ways I will be happy to have NICE and the QOF speaking the same language more often. At the moment we have to cope with at least three different sets of targets. NICE says one thing, single-issue pressure groups such as the British Hypertension Society say another and the QOF says something completely different.

There is a logic to having one voice that considers cost-effectiveness and workload issues together, and valuing a patient's health gain is an admirable aspiration.

And I wouldn't really complain about dropping QOF indicators if the latest evidence suggests they are not cost-effective. Having a national group of experts, chaired by a GP, that will look in a transparent way at the latest evidence for the benefit of what we do must be a good thing. As will be the piloting of new indicators.

So why am I so unhappy about the latest proposals for changing the way practices earn their QOF income? The devil is in the detail and the potential for a rolling programme of new QOF indicators that will substantially increase our workload.

First, a reminder of what GMS2 was all about. Between 1997 and 2004, the number of consultants increased by 42% to 30,650. The number of GPs (not whole-time equivalents) rose by only 6% to 28,800. Advances in medical science and rising patient expectations have combined to bring a massive increase in GP workload. Before 2004, primary care had been facing a recruitment crisis, leading the Government to realise our John Wayne contract (a GP's gotta do what a GP's gotta do) was unsustainable. Along came GMS2, setting realistic expectations of what we could achieve and ensuring new work was linked to funding. Now the Government is proposing that a large amount of the work we took on, and employed staff to undertake, has become part of standard practice and no longer needs to be funded. In other words, we can be given more work for the same money.

Total nonsense

This is nonsense, as practices incur costs in conducting this standard practice. It is the equivalent of telling Tesco that, as I have been buying a standard set of groceries each week for a while, they must now provide them for free and I will spend my money on buying something new instead.

The consultation document admits new indicators will make it harder for us to maintain practice income, but blithely dismisses this as having a 'limited impact' on practices. Perhaps we should just make staff redundant and add to the rapidly rising unemployment figures. I wonder how this would be portrayed in the press.

There are also significant risks for us in the intention not to link income with workload, but instead to patient outcomes. It is already difficult for us to persuade patients to swallow the fifth blood-pressure tablet, without adding to the suspicion that we stand to gain financially from their adherence. And the thought of our income depending on more things that are essentially outside our control, such as weight loss, exercise and smoking cessation, fills me with dread.

We should support the involvement of NICE in the QOF but be very clear about how new work fits in with what we do already. We cannot allow the proposed programme of rolling QOF indicators to sneak in and not be seen as extra work. Our voices must be heard, or else we can look forward to a return to the bad old days of unlimited work for no reward.

Dr Stephen Gardiner is a GP in Bridgwater, Somerset

Should QOF indicators be cycled on a rolling basis? Yes No

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