Should the QOF be judged on costs?
The QOF’s success in improving patient care has come at a high price for taxpayers. It is right that future versions should be demonstrably cost-effective, says NHS Alliance chair Dr Michael Dixon. But the GPC’s Dr Brian Dunn believes the QOF provides the resources to ensure GPs can offer high-quality care, and judging it on costs threatens to take that funding away
The QOF's success in improving patient care has come at a high price for taxpayers. It is right that future versions should be demonstrably cost-effective, says NHS Alliance chair Dr Michael Dixon. But the GPC's Dr Brian Dunn believes the QOF provides the resources to ensure GPs can offer high-quality care, and judging it on costs threatens to take that funding away
The QOF has been a huge success. It has shown how general practice in this country can rapidly rise to meet a new challenge and has made us the most accountable primary care service in the world. Research shows that it has not only significantly improved care but has also reduced inequalities.
This has come at a price for taxpayers and the Government – as the Daily Mail is only too happy to remind us – and both need to know they are getting value for money. This means further development of the QOF should depend upon the proven cost-effectiveness of all interventions added to it. NICE, love it or loathe it, is the only obvious candidate to ensure this happens and its future involvement will provide much needed credibility for patients, taxpayers and the media.
I can see only two arguments against this. The first and most fundamental is that quality in general practice should be an absolute and not subject to calculations of cost-effectiveness. When it comes to the individual consultation, perhaps there should be no limits, within reason. We should preserve our patient advocate role at all costs and continue to put heart and soul (and time) into every consultation.
But the QOF is not fundamentally about the individual patient. It is a national improvement programme using a performance framework that will improve overall health and standards of care. That is not to say it shouldn't be used with compassion and adapted to the individual patient's circumstance, but the framework itself is about populations rather than individuals. It is about doing the greatest good for the greatest number rather than going the very last mile for just one individual. As such, cost-effectiveness has to be part of the calculation.
Arguing against use of cost-effectiveness criteria feels as unrealistic as some of the responses to a recent IPSOS MORI opinion poll of patients. Some 41% said they believed the NHS should provide any effective treatment no matter what the cost. Indeed 31% said they believed the NHS should provide any treatment, even if ineffective, no matter what it cost. As many as 55% said there should be no limits to what the NHS provides.
These opinions are so ludicrous and unrealistic they make you wonder whether democracy really is a good thing! Of course there are limits. If you use all the money on one patient, there won't be any money for the rest. If you use all the money on health, then there won't be any left for housing, education or anything else. Calculations of cost-effectiveness are our way of striking an appropriate balance.
The only other possible counter-argument against the current plans for an analysis of the QOF by cost-effectiveness is that – given cost does matter – NICE is not the right organisation for the job. Much criticism has been levelled at NICE, particularly by interested parties, but however flawed, it is the first serious attempt to distribute health money on a fair and rational basis. Some of its decisions are open to challenge but I defy its opponents to suggest who else should be making such decisions.
Those who oppose the NICE evaluation of the QOF are arguing for a more subjective, possibly professionally dominated approach to quality, which ignores issues of cost. That is how we should run our consultations. It is not how we should develop the QOF.
Dr Michael Dixon is a GP in Cullompton, Devon, and chair of the NHS Alliance
To answer the question of whether the QOF should be judged on costs, it is important to step back and consider why it was introduced in the first place. In 2003, GPs in the UK voted to accept a new contract. This contract defined the services provided as either essential or as additional, and so funded by enhanced services and the QOF. Although this was a GMS contract, the QOF also applied to the 40% of English practices working under a PMS contract, meaning the QOF would cover the care being delivered to the whole UK population.
The QOF was agreed between the GPC and the four departments of health as a recognition that GPs were delivering care previously carried out by hospitals, which had been transferred to general practice without an equivalent transfer of resources. The QOF was meant to resource this care for patients with chronic conditions and deliver an incentive to GPs to improve it.
Fast forward to today and the Department of Health (with admirable amnesia) and NICE appear to believe the purpose of the QOF was to embed the processes it contains into general practice. They appear not to understand that the QOF was also meant to resource the standard of care. GP practices have achieved QOF points because they have invested in staff and premises.
The Government, instead of trying to destroy the QOF, should be celebrating its success. It has resulted in virtually 100% of GP practices in the UK delivering evidence-based care to the entire population of the UK. It is still too early to calculate exactly how great the long-term benefit of better diabetic care, better control of hypertension, better secondary prevention of ischaemic heart disease and better care of asthma and COPD will be on the UK population, but it is likely to be huge.
GPs have delivered this incredibly high level of care for about £20 per head of population. The QOF has narrowed the difference in the level of care delivered to deprived areas and less deprived areas. This is possibly the only Government policy that has been shown to have benefited deprived areas – and ministers want to dismantle it. Why?
NICE, in the DH consultation document, appears to believe GPs are already paid for delivering the QOF by other means and the QOF payment is an additional incentive.
It defines the QOF payment as thus: ‘The QOF payment is considered to be additional to the cost of delivering the indicator; it is regarded for the purposes of cost-effectiveness as an initial incentive to embed within general practice best evidence-based care that will continue to improve patients' care and health'. This statement is either a naive interpretation of the GMS contract or a deliberate attempt to decrease general practice funding.
The QOF payment resources the delivery of the framework, and the high level of structured, evidence-based care it brings. But if you define a QOF payment as simply being there to embed care, rather than as a resource, then as soon as the initial embedding process is over you will judge the payment to be no longer cost-effective. If the QOF payment is removed from an indicator, the resources to deliver that will be removed and although GPs will continue to care for patients, the structured element of disease registers – call and recall and treating to a national standard – will cease, with a consequent reduction in care.
The QOF should be judged on the benefit it delivers to the population of the UK. GPs accepted this revolutionary system and it meant that for the first time doctors would be remunerated according to the quality of care delivered. It is good value. To attempt to put a monetary value on the QOF before it has been properly evaluated reminds me of the definition of capitalists in the Thatcher years: ‘They knew the cost of everything and the value of nothing.'
Dr Brian Dunn is chair of GPC Northern Ireland and lead GPC negotiator on the QOFYes No Should the QOF be judged on costs?