Once a great success story, some leading GPs are now starting to question the direction the QOF is heading in.
Even the chair of the RCGP said last November that she thinks the framework is ‘out of control’,1 while NICE’s QOF development lead is questioning whether it has moved too far from its roots as a tool to improve the quality of care and become more of a payment lever for ministers.
There is no prospect of any stability in the framework any time soon, with the Department of Health planning the most wide-ranging shake-up of the QOF from April since it was first introduced. But has it strayed too far from its original purpose?
It was all so different in 2004: for the first time, GP pay was linked to the quality of care that practices provided and the profession more than rose to the challenge, reaching 90% achievement in the first year the QOF was introduced.
Achievement levels have remained high ever since, but only at the cost of increased workload. Media criticism that GPs were getting a ‘20% pay rise for doing their jobs’ stung1 and resulted in pressure from the Government for practices to do more under the framework.
Evidence also began to emerge that although performance under the QOF had increased in the years before and just after the framework was introduced, this ran out of steam in subsequent years.2
The DH pledged to overhaul the QOF in 2009, refocusing it on outcomes rather than process-based targets.This led to NICE taking control of the process of developing indicators and a step change in the micro-management of the framework.
Since then, GPs have had to cope with increasing numbers of changes to the QOF every year, culminating with this year’s contract changes that will see a record number of indicators replaced in the framework, a hike in the upper thresholds for 20 indicators, a new ‘public health’ QOF domain and a radical change to the way the value of QOF points is calculated.
A problem of definition?
The Government is clear that it has always defined the QOF as a voluntary incentive scheme that aims to ‘reward practices for systematically improving the quality of care given to patients’. It claims that the changes it is seeking for the QOF support this aim.
But NICE QOF lead and original architect of the framework Professor Helen Lester says there is now an urgent need to define what it is for. She says: ‘It is one of the big problems with the QOF. Is it a payment mechanism for GPs or is it a quality improvement tool?
‘I think it would be very useful if there was an agreement that said “the primary purpose of the QOF is…” even though it is nine years later. I think it is quality improvement and have argued this for many years and I continue to argue it.’
The removal of the organisational domain from the QOF from April means practices will no longer be paid for medicines management and keeping patient records up to date. But the GPC says one of the major roles of the QOF is to provide the funding to support practice services and this is being put in danger by the planned changes.
GPC deputy chair Dr Richard Vautrey says: ‘It is unfortunate that the focus has moved to the incentive scheme as opposed to the recognition of the resources necessary to provide staff to deliver quality in general practice.
‘Policymakers have forgotten that in order to deliver good-quality care you need a stable resource to be able to employ staff to deliver the results.’
The inclusion of ‘quality and productivity’ indicators has also been cited by experts as a major source of concern.
Professor Martin Roland, professor of health services research at the University of Cambridge and another of the GP academics originally behind the development of the QOF in 2004, says the QP indicators were a ‘long way’ from the original remit. Responses to a recent NHS Employers survey showed PCT and health board managers struggled to find evidence that some QP indicators have had an impact.
Future of the QOF
All this has led to calls from RCGP chair Professor Clare Gerada for a root-and-branch review of practices’ incentives.
Professor Gerada says the QOF represents too much of GPs’ pay – around 15% according to the DH – and is leading to a ‘distortion’ in the doctor-patient relationship.
She says: ‘The QOF has gone from the sublime to the ridiculous – it is deprofessionalising GPs.
‘We need a rethink of incentives for GPs and must stop this misguided shift towards diseases and metrics.
‘It’s not just that it is a tick-box exercise, it is that it shifts the agenda from what is in front of us to what the computer wants us to do and the QOF has dictated. It has gone from being a reasonably good idea to a tail that is wagging the dog and distorting the doctor-patient relationship.’
NICE says it is continuing to plan new indicators, with a fresh emphasis on public health, and driving the framework towards improving outcomes.
Dr Gillian Leng, deputy chief executive at NICE, says: ‘The QOF from next year will have a public health domain that we have been asked to specifically liaise with Public Health England to work on priority areas for.
‘We want to work with public health priorities, which is to emphasise that we do need an evidence base before we can put them in there.’
NICE advisers have recently decided to pilot alcohol screening indicators and pursue the development of ‘next-generation’ QOF indicators to improve outcomes. So-called ‘tightly linked measures’ (TLMs) are aimed at encouraging GPs to improve the outcomes of selected groups of patients identified through the QOF by combining processes and outcomes into a single indicator.
A TLM indicator for lipid control in patients with diabetes has been put out to consultation this month for the 2014/15 QOF, alongside others incentivising health checks in dementia carers, and points for controlling blood pressure in peripheral arterial disease and using ambulatory blood pressure monitoring to diagnose hypertension.
Professor Lester says: ‘There will definitely be a bigger focus on public health. There also may be more of a focus on patient-suited indicators – for example, asking the patients on the receiving end what it was like to have a review of their rheumatoid arthritis, and feeding that back to the advisory committee so that they could see whether patients thought it was a step too far or was in fact a welcome addition to their usual treatment.’
A victim of its own success?
NICE advisers have also backed a DH plan to ‘bundle’ diabetes indicators to ensure that practices only get their points if they carry out nine checks on one patient.
Dr Leng says this may extend to other areas in time: ‘If you don’t bundle them there is a potential for more challenging ones just not to be delivered. Although there are always critics, on balance, the evidence supports that approach.’
What is certain is that the QOF will continue to evolve over time, but whether most practices will continue to attain high levels of achievement is debatable.
Dr Vautrey says this may be a blessing in disguise: ‘It is a victim of its own success. Practices have stepped up and delivered far higher levels of achievement than were originally envisaged.
‘That is one of the reasons why the Government has continued to focus on the QOF.’
Where is the QOF going?
More emphasis on public health and tackling lifestyle issues, such as alcohol misuse, smoking and exercise
Moving towards more outcomes-based targets in specific patients for instance, ‘tightly linked’ indicators for lipids in diabetes
Bundling indicators to ensure several checks are done in one patient before points are awarded, beginning with diabetes
Including measures of patient satisfaction in the development of QOF indicators
Greater divergence between England and the devolved nations; for example, less stringent rises in upper thresholds in Scotland
The quality and productivity indicators will be reviewed, and perhaps extended if found to be successful at reducing hospital activity
In England, QOF thresholds are set to rise – somet to 100%. In Wales, they will rise to the median while in Scotland, no threshold will rise above 90%