‘No new work without new money'. That was the founding principle underlying the 2004 GP contract, the phrase rehearsed at every LMCs conference since, the sine qua non of the profession's support for a new system of GP funding. Eight years later, as the profession confronts an ever-lengthening to-do list on the back of successive pay freezes, it seems an increasingly sour joke – and nowhere more so than with the QOF.
The NICE QOF advisory committee has been in operation since 2009 and with the piloting and review process now fully up and running, each year a dizzying array of indicators is put forward for inclusion and removal.
Recommendations for 2013/14, published last week, could see up to 16 indicators heading in, and 14 indicators heading out, through the QOF's revolving door.
Tasks that GPs could no longer be paid for to perform include prescribing ß-blockers in heart failure and measuring blood pressure in patients with chronic kidney disease, while new targets could include checks in patients with rheumatoid arthritis, looking for erectile dysfunction in diabetes and controversial ‘biopsychosocial' assessments for patients with depression – a 16-point analysis which will include looking at everything from patients' living conditions and financial worries to the quality of their interpersonal relationships.
Then, of course, there are the wild card indicators, outside NICE's remit, added at the behest of the Government. The quality and productivity indicators brought in last year marked a real departure for the QOF, incentivising GPs for the first time on the basis of efficiency savings.
Our investigation this week reveals many practices struggled on the prescribing efficiency indicators, with around a quarter dropping points.
Explanations offered include patient reluctance, lack of time and the fact that for many this was only the latest in a series of prescribing crackdowns. But when long-serving GPC negotiator Dr Peter Holden blames ‘target fatigue' and claims GPs are in ‘sod-it mode', it suggests GPs are simply being asked to tick too many boxes for too little reward.
It is all very well negotiators bemoaning the QOF's unrealistic expectations, but they have struggled to make their views heard where it counts, in the negotiating room. The prescribing efficiency indicators have already been scrapped, but they were replaced with a new indicator that linked GP pay to reducing A&E attendances – a target which may or may not be within GPs' control. Unpopular depression screening indicators, recommended for removal by NICE last year, were somehow spared the chop. There are even plans to bundle diabetes indicators into one daunting composite target.
The QOF remains, at its best, a valuable way of rewarding focused interventions for specific disease areas, and is admired internationally. But its perpetual evolution is distracting and demotivating to many, and the shoe-horning in of political targets and furious lobbying by various pressure groups at the negotiation stage make a mockery of a supposedly evidence-based review process.
Our columnist Dr Margaret McCartney this week praises the lost art of standing still, and what applies to clinical diagnosis could apply equally to the QOF. The framework would benefit from a pause to take stock, let practices catch up and allow real debate over how GP pay incentives should work.
As it happens, LMC leaders at their conference in May thought the same, unanimously backing a motion demanding ‘no changes are made for the next two years in order to accommodate the changes to commissioning'. That makes it official GPC policy. As the next round of contract talks gets underway, negotiators might take that as their starting point.
