Government targets distorting GP/patient relationship?

James Gubb, 20 November 2008

The Quality and Outcomes Framework (QOF) has lofty aims. In linking up to a third of general practice income to achievement against a series of quality indicators, it hoped to deliver significant increases in quality to patients. Has it succeeded?

Looking purely at quality indicators included in the QOF, the strategy appears to have been vindicated. General practice returned an average of 91.3 per cent of the maximum possible score in the first year (2004/05), rising to 96.8 per cent in 2007/08 – significantly higher than was anticipated by the Department of Health. Concomitant with this, there have been step-changes in clinical quality for patients with certain chronic diseases, such as asthma and diabetes. Health inequalities on QOF quality indicators have also fallen, with faster improvement in practices in the most deprived quintile reducing the difference in performance with least deprived from 4.0 per cent to 0.88 per cent.
However, all is not so straightforward. Quality of care is hard to conceptualise and measure in ways which capture the full range of issues that matter to patients and can be applied day-to-day. The QOF’s focus is primarily on technical effectiveness – on health promotion and the evidence-based treatment of particular chronic conditions in the biomedical model – but, as the American statistician, W. Edwards Deming famously warned, in most cases 97 per cent of what is important either isn’t measured or isn’t measurable. The QOF neither includes all medical conditions nor captures the essence of a primary care consultation, the vital relationship between doctor and patient. The fear that the financial incentives in the framework would divert attention away from these areas to meeting QOF targets is in evidence.
Quality – and improvement in quality – can be substantially worse for those with conditions outside the framework, particularly when concerning the elderly. Across eighteen practices between 2003 and 2005, achievement against fifteen indicators concerning depression and osteoarthritis (not in the original QOF) increased by just one percentage point from 35 per cent to 36 per cent, compared with a 16 percentage point improvement in incentivised indicators relating to asthma and hypertension. Consultation rates for depression and anxiety also fell; and in face-to-face interviews in the English longitudinal study of ageing, 75 per cent reported receiving endorsed quality of care for conditions included in the QOF, compared with 58 per cent for those not. For certain non-incentivised conditions, such as falls management (41 per cent) and osteoarthritis (29 per cent), the picture was worse.
More widely, the QOF encourages GPs to focus on the treatment of professionally-defined diseases, not on the health problems as patients’ experience them. Medicine is an inexact science. Otherwise sound clinical guidelines may not be appropriate in treating patients with multiple health problems. The consideration of social context, the amalgamation of appropriate consulting skills and styles, the identification of patients’ priorities and concerns, and the involvement of patients in decision-making, as well as pure technical quality, are all associated with positive outcomes; yet the QOF draws attention elsewhere and tends to place a ‘second voice’ in the head of the GP. At the extreme, some practices have reportedly started to neglect cultural attitudes towards patients and ‘bish-bang-whallop through the scoring’; but more commonly, the QOF has caused the inadvertent diversion of attention or the odd bit of ‘gaming’ the system. In one survey, 75.9 per cent of nurses reported that they felt the framework was undermining the patient focus of the NHS.
There is a strong case that the QOF should be both downscaled and downsized to give greater priority to patient-need and the professional judgment of the doctor.
• The proportion of income it is possible to derive from the QOF could be reduced, to around the seven per cent suggested by the Health Foundation’s director Professor Martin Marshall.
• The number of indicators in the QOF could be cut and – while open to new evidence – confined to clinical indicators, such as ACE inhibitors for heart failure or influenza immunisations in over 65s, which have been rigorously proven to deliver significant, cost-effective, health gain to many.
The question can be posed as this: Do we really want GPs to be a set of what the cultural critic Raymond Tallis has termed ‘sessional functionaries robotically following guidelines’?
The full report, Checking-Up on Doctors: A Review of the Quality and Outcomes Framework for General Practitioners is available here.