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Any new GP contract must cut back on QOF work

No other country leaves GPs’ income so dependent on performance-related pay, argues Professor Martin Roland, so a new contract should reflect what the past decade has taught us

As the Government heads towards a new GP contract, the development - or abolition - of the QOF will weigh heavy on many GPs’ minds during the process. Ten years in, we have become accustomed to working with the QOF, but there’s still a lot that could be improved.

The push to include all of medicine in QOF should be resisted. The QOF is never going to cover more than a small proportion of consultations (albeit an important one), and my view is that the QOF should be smaller and account for a smaller proportion of GPs’ income.

The reason that it should account for a smaller proportion of income is to reduce its importance in the eyes of GPs and so reduce the unintended consequences of the framework. While it has undoubtedly led to improvements in processes of care, it’s far from a magic bullet for quality improvement. Guidelines, clinical audit, education and other approaches to quality improvement remain important and should not be forgotten.

Furthermore, the QOF has led to some aspects of care getting worse.¹ We showed this for some clinical conditions which were not incentivised, but the most obvious example is how the 48-hour target for appointments to see a GP led to booking systems that perversely made it more difficult for patients make appointments, especially with the doctor of their choice.

Support common practice

So let’s make the QOF smaller, and have GPs’ income made up from other sources. Let’s also be more careful about the selection of indicators. While the original QOF was controversial, there wasn’t that much criticism of the original set of indicators. This is because these were ‘low hanging fruit’ - things that GPs by and large thought they ought to be doing, and mostly were. Since then we have had a series of indicators introduced which sought to change what GPs thought was ‘good practice’ - the PHQ-9 indicator for depression is the best example - and other indicators where the evidence base was not that strong.

We should stick to indicators which are in line with widely accepted good clinical practice. Research shows that external incentives can damage professional motivation if they’re not in line with core professional values. We need to make sure this doesn’t happen with the QOF.

Promote continuity, and appropriate treatment

I’d like to incentivise continuity of care. This has declined in recent years for many reasons that GPs will understand well. While I understand that patients like continuity of care, I think it’s increasingly important for GPs. How else can we deal safely with an ageing population of patients who have an increasing number of complex problems in a 10 minute consultation?

However, continuity can only be incentivised with a very light touch - anything too numeric risks gaming. Despite the problems, I think we could incentivise ways of organising practices to promote continuity, such as those suggested by the RCGP.² We need to challenge the continued view of politicians that access matters and continuity doesn’t.
It’s also a mistake to increase the top thresholds too much, or at least to do so without expecting and allowing an increase in exception reporting. Exception reporting is a critical part of the QOF that helps GPs to ensure that their treatment remains relevant to the needs of their individual patients. There are plenty of people who would like to abolish exception reporting, but these calls need to be resisted otherwise we risk having a scheme that harms patients.

Overall, I’m in favour of the QOF. It’s right that GPs should get more income for providing better care, especially where that means increasing practice staffing levels and other expenses. The alternative (the old system) is that GPs who provided the best care took home less pay. That hardly seemed fair, though it’s of course still the case for GPs who choose to provide a high standard of care for small lists.

But GPs’ pay needs to be a balance of basic allowances, capitation and quality payments. Getting this balance right is something that health care systems in all countries struggle with. No other country has made as much as 25% of doctors’ income dependent on a ‘pay for performance’ scheme like the QOF, and we shouldn’t either.

Let’s use the opportunity of a new contract to maximise the gains we’ve made with the QOF - and minimise the harms.

Professor Martin Roland is Professor of Health Services Research at Cambridge University and a part time GP in Cambridge. He advised the government and BMA negotiating teams on the development of the original QOF from 2001 to 2003.

References
1 Doran T et al. The effect of financial incentives on incentivized and non-incentivized clinical activities. Evidence from the UK’s Quality and Outcomes Framework. BMJ 2011; 342: d3590.
2 Hill A, Freeman G. Promoting continuity of care. RCGP.

Readers' comments (12)

  • Average take home pay per consultation is £ 3.50. Average consultation per patient is approaching 7 a year and is going to increase with the silver storm of multi morbidity. GPs are seeing 40+ patients, some over 60 patients [ 10 hours of face to face consultations] per day. No wonder a large number of GPs are depressed, burnt out and leaving.
    A new contract must address safety - how many patients is it safe to see ? Also, it must address how many appointments per 1000 patients per day.
    Why do we GPs stay in this horrible, nasty NHS?

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  • I didnt vote for the last contract as I could see where QoF would take us. The lunacy being added to by the fact that changes could be made totally unilaterally with 3 months notice. Constant changes achieve nothing.

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  • Any new contract will only be because the government of the day is again forcing through what it sees as the most pressing issue of the moment - queues at A&E, without any longer term view, because they know they're only in power until 2015. Hence OOH dumped onto us again. I think some poor GP will commit suicide because of the workload and only then if even, after much hand wringing and pointless inquiries about 'political pressure on GPs ' ( of course denied by politicians ) will they decide that GP workload needs addressed and will siphon more off to the private sector. It would be much easier if they just came out and said ' look we hate GPs and are determined to make them all disappear '.

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  • Why indeed do we stay ? It is baffling. Pensions changes that cut pay, but no changes to a lot of other public workers. The NHS is discriminatory and bullying. An Occupational Physician in the BMJ called the NHS - brutal. Why do we stay? Can we not do better than 3.50 take home pay per consult?

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  • Scrap QOF please.

    With the same money pay for the numbr of patients who have seen a clinician in the pratice to plan their health goals for the up comming year.

    Net effect will be a health literate population with a better chance of not getting an expensive LTC.

    Also less prescriptions issued and more time for delivering high quality service to really ill people.

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  • It is impossible to see a GP of choice at any time let alone in 48 hours!

    One of the reason sit is impossible to see a GP in 48 hours and even more impossible to see a GP of choice, it because they are all too busy 'ticking boxes' on bits of paper.

    It is time the NHS allowed GP's to do what they trained to do, care for the sick!

    Every time there are any changes in the NHS it is GP's that take the bashing, but without GP's there wouldn't be an NHS!

    I wonder how many boxes the NHS ticks fro each GP they bash? It must be a soul destroying job which perhaps accounts for the tiny number of white, British GP's there are in the system?

    Any GP with a good brain would get out of Britain as soon as they have qualified.

    Let's not forget the GP's are human beings too, they have families and should have a right to spend quality time wit them, they have a right to rest to be fit to do their work and a right to be treated so much better than the NHS treats them at present!

    start looking at hospital doctors who work office hours, consultants that use hospital facilities to earn private money, out patient departments that work office hours ... leave our GP's alone and start paying them what they are really worth!

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  • It's certainly a struggle. We can't show improved outcomes compared with other countries because the population has enough wealth to: a) eat themselves sick, and b) take no exercise. In spite of this high morbidity, evidence shows that it's the GP system that makes NHS so high quality and so cost-effective. However GPs and GP representatives aren't known for paying into political campaigns or crossing politicians' palms with silver/gold (compare with BBC, for example). Is it any surprise that we don't get laws or policies in our favour? Yes there are a few good politicians, but they stand out all the more because they are so rare.
    So - perhaps we should just decide what we want, and then pay some politician to deliver it for us? Has it really come to this?

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  • 'Average take home pay per consultation is £ 3.50.'
    This kind of comment is not helpful.
    Any full time GP who makes £10-14k for 3000-4000 consultations a year should close their practice and get a salaried or locum job.
    Anon keeps making this comment and it distracts from the important discussion.

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  • Anon is lucky to make £ 3.50. My practice here in wet NI does not do as well.
    Here are the figures. Total pay per patient per year is £ 115.00. Profit after expenses £60.00. Tax/ NIC £ 30.00.
    Take home pay = £ 30.00.
    Average consultation rate = 6 in NI. = £ 5.00 apparently take home. But consultations only 60 % of workload. So, it is £ 3.00 here. Admittedly. my accountant agrees, there are others who earn far more.
    But, work it out. Even they don't earn more than £ 4.50. Maybe, in some places in England average consultation is only 3.
    Anyway, 40 consultations a day [ x 3.50] = £ 140.00 for anon, + 40% for other stuff = £ 196 per day . X 22 days -= £ 3512 take home or £ 7000 before tax ie £ 84000. Not bad for 22 days. Hey, still only £ 3.50.
    Different arithmetic anyone?

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  • I found the answer to all this nonsense was to leave the UK.

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