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QOF is the envy of the world – let’s keep it that way

Professor Helen Lester explains the importance of piloting QOF indicators and how it vastly improves the way new points are introduced into the framework

QOF piloting has now entered its second year. It's been an interesting learning process all round but I think I can safely say that after years of boring anyone who'd listen about the importance of piloting, the process is finally bedding in and beginning to show its real worth.

The first pilot was always going to be an interesting hybrid of the old and the new systems. The resulting indicators were safe but didn't push the boundaries of quality improvement. However the indicators that didn't make it through that first piloting process, particularly 'The percentage of patients on the palliative care register who have a preferred place to receive end-of-life care documented in the records' demonstrate the value of the process in protecting patients from unintended consequences.

This seemingly straight forward indicator was used as part of an holistic approach to palliative care in most pilot practices. In a small minority, it appeared to be asked out of context at inappropriate times and repeated very frequently until the patient expressed a preference of some kind. If the palliative care indicator had been introduced without piloting, this might have incentivised poorer care in a minority of practices with potential harm to vulnerable patients. Since there are currently over 53,000 people on the palliative care register, if only 10% of practices had ‘missed the point,' over 5,000 vulnerable people may have been distressed in an unnecessary manner. I am almost certain that in the pre-pilot QOF system this indicator would have sailed through with flying colours.

The pilots have not been without their own mini dramas. Practices pull out at the last minute. Practices sign up, but become overwhelmed by the stuff of everyday primary care and occasional unexpected events. The IT extraction processes have also proven to be more complex than I think anyone expected with PRIMIS and the NHS Information Centre working extraordinarily hard to ensure that the pilot indicators are as close to live QOF as possible. However we've now settled into a QOF pilot pattern with a sense of seasonality to the work and with practices who are happy to engage with new and, I hope, more exciting and clinically important indicators.

QOF is often envied by those working outside the UK where it's almost impossible to create the immediate buy in to a new way of working that a QOF indicator can. It's therefore even more important to ensure the indicators themselves are robust and incentivise actions that make sense to patients and practitioners and which genuinely lead to better patient care.

Indicators in pilot three have focused on public health issues such as brief interventions for obesity. We are also looking at the possibility of piloting a new type of measure in QOF that recognises quality care for patients who are unlikely to achieve all or nothing targets.

Professor Helen Lester is a GP in Birmingham and QOF pilot lead