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QOF exercise targets are at risk of becoming another meaningless ‘tick-box’

It’s been a long time coming but finally, physical activity has been introduced in the 2013/14 QOF indicators for hypertension. This has to be welcomed. Evidence shows that physical inactivity is the biggest public health threat of the 21st century.1

There is not one single solution for increasing activity – and our efforts are futile if we see no investment in school programmes, transport policies, urban regulations and infrastructure – but we should not underestimate our unique position and power to influence patients. The average patient sees us four times a year, and the average surgery will see nearly 80% of its patients at least once a year. We are therefore in the ideal position to help our patients when they reach their point of curiosity or willingness to change.

Practical application

Many of us feel deflated by the seemingly unachievable QOF changes this year and, because of this, the new contract may have drawn GPs’ attention away from the physical activity agenda. In future, we are likely to see further physical activity indicators added for other diseases, but before NICE does this, we need feedback on the quality of the current indicators, and their practical application during consultations.

The tool used to record physical activity status in the QOF this year is the GPPAQ. It is a validated tool for identifying activity status but, like many tools that come from academia, translating it into practice usually has its hiccups.  Although the GPPAQ the simplest validated tool out there, it has a few issues that we all need to be aware of if we are to fully understand and use it.

Some of your patients may have been calculated as being ‘less than active’ despite religiously doing, as guidance tells us, 150 minutes of moderate intensity activity, such as brisk walking, per week. This is because the level of activity ‘result’, despite featuring in the questionnaire, does not consider DIY, housework and walking.

The reason for this is due to over-reporting of these activities. Many GPs still don’t know about this basic problem.

Furthermore, you need to use a computer to generate a result from the GPPAQ and even though this means that we don’t lose time calculating things ourselves, the way a patient’s activity level is calculated is unclear for both the patient and doctor. As a doctor or a patient it’s important to understand the method used to reach a diagnosis or conclusion. Using this particular tool is confusing as it doesn’t acknowledge the simple recommendation that everyone should do 150 minutes of moderate intensity a week. Try it yourself now - if you input into the GPPAQ that you do 150 minutess of brisk walking a week, it says that you are not active.

No more ‘tickbox’ culture

I am not suggesting that the GPPAQ is wrong - it’s a validated tool - but if we are going to induce physical activity discussion with our patients smoothly then it is really important that both parties understand the mechanics of how physical activity is measured in the first place.

My overriding fear is that the GPPAQ will follow in the footsteps of the PHQ9 (or similar depression scores). Emphasis on completing the PHQ9 had begun to take over the process of exploring the biopsychological issues which by its own virtue is part of the management of depression. Patient information does not work - patients need engagement and well-targeted messages. Using tools like the GPPAQ and the PHQ9 distracts the clinician from fully exploring a patient’s beliefs before offering advice.

If the GPPAQ is here to stay then before it is introduced to other indicators, we need to make sure we provide feedback on whether this current format works for GPs in practice and so I urge NICE to listen to GP concerns before writing the GPPAQ into the QOF again next year.

Introducing indicators to measure physical activity was a good first step but, going forward, we must make sure that we give this major health threat the correct care and attention it deserves.   

Dr Ricky Shamji is a GP in Birmingham


1 Blair S. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009;43:1-2.


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