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A smaller QOF would be a timely blessing

How much housework have you done? GPs are asking this of millions of patients up and down the country, simply because NICE says so. It’s in the QOF. It’s part of the GPPAQ.

But QOF is voluntary, you say. Don’t do it. The real reason we do it is to fund the nurse down the corridor, because the capitation per patient is so darn low. That’s why.

There is no certainly evidence base behind this question. The DH itself says ‘[the questions] have not been shown to yield data of a sufficient reliability to contribute to an objective assessment of overall physical activity levels’.1

When there are so many boxes to tick that the consultation is starting to resemble a call centre script that 111 would be proud of, should we ask has QOF had its day?

No - I like the QOF. I would gladly kiss the feet of the people that invented it.

But it could do with being put in proportion, cut down to size. If general practice were a supermarket and core, additional and enhanced services and QOF were the product lines, then QOF used to be the star performer and essential services were the loss maker. However, now the QOF is so onerous, it struggles to bail out poor old essential services as it always did before.

The poor old essential services need a bailout, and the best way to do this is by shrinking the QOF.

The best way to cut it

Shrink the onerous QOF and place it in essential services, paid through the global sum equivalent (GSE).  Follow the ‘Scottish precedent’, where the organisational QOF domain funding was placed in the GSE. The Scottish government’s decision as it speaks volumes of how it trusts general practice to be professional without policing it with a multitude of hoops to jump through.

The main concern about GPs calling for a smaller QOF is that NHS England might try to shrink the QOF and take the funding out of general practice altogether. If it did this, would the last GP please switch out the light?

Recall that the GPC had to negotiate a necessary evil, the ‘evidence lite’ Quality and Productivity (QP) domain in order to stop the funding evaporating from general practice. Government and its bureaucrats love data, it helps them to manage GPs and convinces them that they have got ‘bang for their buck’. This is fine whilst there are plenty of managers to crunch the data, but the area team, CCG and CSU staff numbers have been cut to the bone.

But leaders at NHS England have the opportunity is there to be brave. I’m calling on them to cut the number of tick boxes and give the funds ‘no strings attached’ to resource a general practice in crisis, and to cut the QOF to 800 points by ending the QP domain and putting the funds from those 100 points in to the global sum equivalent. The evidence base within the QOF will increase instantly if they do so, and NHSE will restore GPs’ respect for the scheme.

The most ‘creative [way] to incentivise GPs’ is to shrink the QOF but keep the funds in core general practice.2 It is a blissfully simple way to re-professionalise the practice of medicine in UK general practice. It saves NHS management time too. A GP without boxes to tick is free to tackle the insatiable demand of the aging population and the rising chronic disease burden more effectively.

Unconditional resourcing

Funding ‘with strings attached’ increases stress, uncertainty, furtive night-time number-crunching and reduces patient access and GP morale. It risks creating a vicious cycle of control where the more hoops, boxes and strings there are, the less inclined general practice is likely to engage with NICE, NHS England and Government agendas.

A general practice funded with no strings attached doesn’t need recruitment drives and a golden hello. On the other hand, a transfer of QOF funds to a ‘permanently temporary’ DES will foster further instability in uncertain times.

And so, back to the question on housework. Should we bin GPPAQ? Well, the fact PHQ-9 was removed gives us hope. We could shorten the GPPAQ, as we did with the AUDIT-C form of the full alcohol questionnaire. Why not ask:

- Do you have a job that involves vigorous physical activity?

‘Yes’? Stop. The patient is active; ‘no’? Ask the next question.

- Last week did you do three hours or more of physical exercise or cycling?

‘Yes’? Stop. The patient is active; ‘no’? Perform a brief intervention to encourage more exercise.

It is less heavy on the use of the questionnaire, but gets the point across. And at least it might put us messy ones at a lesser risk of embarrassment.

Dr James Parsons is a GP in Sheffield and former deputy chair of the GPC trainees’ subcommittee.


1 Department of Health. The General Practice Physical Activity Questionnaire (GPPAQ). 2006

2 Pulse. Smaller QOF being considered under radical rethink of GP contract by NHS England. May 2013.