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What does the future hold for the QOF?

The ashen-faced expressions told their own story. It’s fair to say that GPs’ overwhelming success at meeting targets set in the first year of the QOF did not fill officials at the Department of Health with unconfined joy.

By Lilian Anekwe

The ashen-faced expressions told their own story. It's fair to say that GPs' overwhelming success at meeting targets set in the first year of the QOF did not fill officials at the Department of Health with unconfined joy.

‘I gave a presentation at the department and showed officials all the areas in which GPs had done so well and achieved so highly on the QOF targets,' says Professor Julia Hippisley-Cox, professor of primary care at the University of Nottingham.

‘Their faces went completely white. They were absolutely aghast. I was saying "Look at what the data shows, isn't it great how quickly GPs have adapted?" and they all looked ashen. The problem was they set the baseline for achievement far too low.'

Now speculation is growing that the Government may act to tackle a framework which for some in Whitehall – and for some leading GPs – has seen GPs far exceed targets but at the same time seen the QOF fail to meet expectations for improving care.

Radical change

Last month's National Audit Office report finding the new contract had cost £1.76bn more than expected while the QOF had only brought ‘moderate improvement in outcomes in some long-term conditions' did not help its cause.

Even the authors of the QOF concede it is time for potentially radical change. Professor Martin Roland, director of the National Primary Care Research and Development Centre and the joint architect of the framework, recently cautioned that ‘the size of the QOF cannot increase inexorably'.

‘Some indicators or conditions should be removed,' he told Pulse. ‘Perhaps indicators could be removed on a rotating basis, for example on a three-year or four-year cycle'.

Professor Roland also suggests that the proportion of a GPs' income that is derived from QOF-related performance should decrease in future; sentiments shared by the QOF's co-architect, Professor Martin Marshall, director of the Health Foundation.

His recent report - Financial Incentives Healthcare Providers and Quality Improvements - on the impact of financial incentives on quality improvements found offering financial incentives to GPs is unlikely to have a dramatic impact on the quality of patient care.

‘If we were planning QOF now, with the evidence at our fingertips, then we would do some things differently,' he says.

‘Linking such a large proportion of practice income to measurable aspects of care has threatened the holistic and patient-centred focus of traditional general practice. And it certainly doesn't seem to have improved the extent to which the public value general practice, or GP's morale.'

Dr Nick Summerton, reader in public health and primary care at the University of Hull and a GP in the city, agrees that the QOF threatens holistic care and is ‘not very individualised'.

‘I have always been pretty anti-QOF from the beginning. My problem with the QOF was that it directs clinical priorities and makes people concentrate on some areas in preference to others.

‘Going forward, perhaps we need to say "Is it time for the end of the QOF?". I don't think GPs will ignore different areas or patients with certain problems because there's no money attached to it. To say "GPs don't do non-QOF work" is an indictment of general practice.'

But whether justified or not, there remains a perception that a chronic condition needs to have QOF points attached to be taken seriously in primary care. There was outrage among many GPs when the Government rejected all of the GPC's proposals for new clinical indicators for 2008/9 – peripheral arterial disease, osteoporosis and heart failure, and a new points ratio for CKD – in favour of extended hours.

Dr Sally Hope, a GP in Woodstock, Oxfordshire, who was on the QOF expert review panel that approved osteoporosis, says she felt angry that the hard work that had gone into compiling the evidence for inclusion of osteoporosis had gone to waste.

Would a rolling QOF be a solution? ‘Not really', says Dr Hope. ‘I don't see how that would help, because the clamour would then be to get on the list for the next cycle, the next time round. It would just replace the clamour for one thing with another.'

Last week's hearing by the Health Select Committee, into health inequalities, offered a glimpse into how the QOF might change in the future.

Mark Britnell, the Department of Health's director general of commissioning and systems management, told the committee the QOF had been ‘very progressive' but ‘always needs to be reviewed'.

‘The Darzi review will be looking at making the QOF more relevant for the people we serve. After the Prime Minister's speech about prevention, we will also looking at making the QOF broader and using it in the promotion of well-being – in areas such as smoking, diabetes and CVD.'

Professor Roland thinks that ‘for all its faults, the QOF is an interesting example of how it has been possible to introduce an infinitely flexible framework which has put quality improvement high on the agenda'.

But he adds, ‘It was never intended or expected that the indicators would stay static. They should develop and improve as it becomes possible to include new areas, or new evidence becomes available.'

It's a difficult balance to strike – reflecting established clinical consensus while also being forward-looking.

And sometimes the QOF does get left behind. New draft NICE guidance on chronic kidney disease asks GPs to measure and treat proteinuria, and points towards a growing disparity between the institute and the QOF.

Not keeping up

Professor Mike Kirby, professor of health and human sciences at the University of Hertfordshire and a retired GPSI in urology, believes the QOF is no longer keeping up with the evidence. ‘When the QOF was introduced it was meant to be evolutionary and it doesn't look like that is the case now', he says.

‘It's disappointing because I think we achieved a lot with it, in terms of more systematic management of patients, but medicine moves on all the time.'

The NAO report rather paradoxically recommended that the way to ensure the QOF kept up with changing evidence was to plan negotiations in advance, advising that the department ‘should develop a long-term strategy to support yearly negotiations [and] should be based more on outcomes'.

Professor Hippisley-Cox agrees. ‘The reason the QOF was made the way it was is because that's what they thought would work, and it's practical and we can count and measure performance. But it can't stay the way it is and in future the Department of Health should plan things more strategically.

‘I hope future QOFs include more outcomes measures. We can be achieving near-perfect scores for coronary heart disease, but we can't prove we've reduced the number of heart attacks. The QOF can make us think we are doing fantastically well, but we might not be. It would be good to show other people that all the work we do is worthwhile.'

A QOF that could prove it was saving lives? Perhaps even those officials at the Department of Health might manage a smile at that.

What should QOF 2018/19 look like?

Professor Julia Hippisley-Cox, professor of general practice at the University of Nottingham:
‘If I was in charge of designing future QOFs I would make a list of all common disease areas and then for each of those diseases come up with some standards of what could be incentivised. Then work out the baselines and look at what the shortfalls were and where the biggest gains could be made. And then, once we've achieved a certain number, then that should go and we should include something else.'

‘In 10 years time I would like to see some sort of equity audit, to identify gaps between people in affluent and deprived areas and reward GPs for reducing the difference. I'd also like to see targets based on patients' individual profiles.'

Professor Martin Roland, professor of primary care at the University of Manchester:

‘I think it will develop so that it better represents patient-centred care. At the moment it tends to focus on disease and it will mature so that it will better reflect patient centredness.

‘There should also be more emphasis on patient questionnaires. Continuity of care should be incentivised. I would personally do this by using patient questionnaires and making the results publicly available. I would not pay GPs for that but we should make a start by really getting a good handle on how much patients value continuity of care, and thinking of ways to reward GPs for that.'

Professor Martin Roland: co-author wants changes to QOF Professor Martin Roland: co-author wants changes to QOF Professor Mike Kirby Professor Mike Kirby

When it was introduced it was meant to be evolutionary, but it doesn't look like that is the case now

Professor Martin Roland Professor Martin Roland

It was never intended that the indicators would stay static

QOF computer

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