CIVITAS: Checking-Up on Doctors: A Review of the Quality and Outcomes Framework for General Practitioners – 19 Nov 08
Government targets drive a wedge between doctor and patient
The relationship between GPs and patients, based on trust and professional integrity, is being undermined by the government's culture of targets, according to a new report from independent think-tank Civitas.
In Checking-up on Doctors, James Gubb, director of the Civitas Health Unit, and Grace Li examine the Quality and Outcomes Framework (QOF), currently out for consultation by the Department of Health.
They accuse the framework of offering inappropriate financial incentives that can distract GPs from providing high quality personalised care for patients. 'The QOF', they say, 'should be downsized and downscaled sooner rather than later.'
Medicine becomes a 'game' to score maximum points
In linking up to a third of general practice income to performance against a range of quality indicators (see notes to editors), the QOF has placed GPs in a 'game' to get maximum points and income.
This is dangerous. There are many reasons why high quality care for patients, particularly the elderly with complex medical conditions, may not fit well with what is mandated by the framework. This opens it up to abuse. Some practices have artificially boosted QOF scores by inappropriately excluding patients or adjusting the reported prevalence of disease. In 2005/06 such 'exception reporting' was considered above normal in four per cent of practices (pp.22-25).
A 'second voice' in the surgery
Quality in general practice depends not just on 'technical effectiveness' (the focus of the QOF is almost solely on clinical performance), but also effective interpersonal skills and the relationship between doctor and patient that produces feelings of confidence and peace of mind.
Yet the QOF's priorities may not be the same as the patient's when they consult their GP. In producing a 'second voice' in the consultation, there is a real risk of the framework driving a wedge between doctor and patient, with unknown and concerning consequences. In one survey, 75.9 per cent of nurses said they felt the QOF was undermining the patient-focus of the NHS (pp.27-29).
Paying out for quality already there?
In its aim of improving clinical quality for chronic disease management, the QOF has delivered benefits. A more pro-active approach has been encouraged and treatment has improved. Quality of care for diabetes and asthma increased at a faster rate post-QOF as opposed to pre-QOF, with greater improvement between 2003 and 2005 than the five years prior to that (pp. 14-15).
Practice Quality Improvement
Source: Campbell, S, et al., Quality of Primary Care in England with the Introduction of Pay for Performance, NEJM 2007;357;2
Health inequalities on quality indicators included in the QOF 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 (pp.19-21).
However, the improvement in clinical quality that the QOF has engineered has been less dramatic than was anticipated. Many indicators are not associated with significant health benefits and, for some conditions, quality was already improving quite rapidly. Improvement in quality of care for coronary heart disease, for example, has continued at the same rate (pp.15-16).
There is a real sense in which the QOF paid out for quality that was already there, but not well recorded.
Patients with conditions not in the QOF worse off
Those conditions not covered by QOF targets have shown far less improvement, if any. Achievement across 15 indicators relating to depression and osteoarthritis increased by just one percentage point from 35 to 36 per cent between 2003 and 2005 (pp.25-26).
Practice Quality Improvement outside QOF
Source: Steel, N, et al., Quality of clinical primary care and targeted incentive payments: an observational study, B J Gen Pract 2007; 57: 449-454
Patients presenting with these conditions could actually be worse off as a result of a system of financial incentives that tend to direct their doctor's attention elsewhere.
Downscaled and downsized
James Gubb and Grace Li recommend that the QOF should be downscaled and downsized to enable general practice 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 should 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 should 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.
'Medicine is an inexact science' says James Gubb. 'In encouraging more of a "medicine-by-numbers" approach, there is a real risk that in the long-run the QOF could inadvertently cause a decline in general practice's ability to probe symptoms, explore probabilities and give proper attention to the concerns of patients.
'Do we really want GPs to be a set of what the cultural critic Raymond Tallis has termed "sessional functionaries robotically following guidelines" or do we want professionals able to work for their patients?'
Notes
i. Civitas is an independent social policy think-tank. It receives no state funding either directly or indirectly and has no links to any political party.
ii. The QOF links up to a third of general practice income to meeting a series of targets relating to quality of care. The majority (650 points out of 1,000) of these relate to (largely) evidence-based clinical standards, but there are also points available for practice organisation, the provision of additional services and (to a lesser degree) attention to patient experience. For example, 57 points relate to the percentage of patients with hypertension having a blood pressure of 150/90 or less following a BP check in the last nine months; five points are available for producing a list of patients diagnosed with cancer since 2003.
iii. 'Checking-Up on Doctors: A Review of the Quality and Outcomes Framework for General Practitioners', by James Gubb and Grace Li is published by Civitas, 77 Great Peter Street, London SW1P 2EZ (tel. 020 7799 6677) and can be downloaded here.
Foreword
In one of Somerset Maugham’s plays a rather elegant lady announces that she intends to see her doctor. ‘I didn’t know you were ill’, says her friend. ‘I’m not,’ she replies, ‘but half a guinea is very little to pay for the pleasure of talking about yourself without fear of interruption for fifteen minutes.’
As James Gubb and Grace Li argue in this examination of the way in which the government funds primary health care, there is more to a consultation with your GP than getting a diagnosis and a prescription. The satisfaction people feel about their relationship with their GP has as much to do with manner as with technical expertise. A good GP listens to what you have to say then asks you about what you haven’t said. The GP probes the symptoms for the cause, and considers what you are saying now in the light of what you said on your last visit to the surgery. The calm satisfaction that is gained from a consultation with a GP who you really feel cares about your welfare is probably as great as the benefit you are going to get from the drugs. As the motto of the Royal College of General Practitioners puts it, GPs must mix science with compassion.
This causes problems in the climate of targets and incentives that currently pervades public services. It may not improve the patient/doctor relationship if the doctor is under pressure to boost the practice income by taking blood pressure and offering advice on smoking and diet, while the patient wants to talk about something that is not incentivised by extra payments.
On the other hand, do we want to return to the days of relying on the professionalism of doctors and expecting them to do the best for their patients without any external form of monitoring? There have been dramatic swings in the way in which we regard doctors, from the sawbones and charlatans of eighteenth-century satire to the self-sacrificing idealists of Victorian novels and the Golden Age of Hollywood. The truth probably lies somewhere between the quacks of Hogarth’s engravings and My Brother Jonathan. Doctors are still members of homo sapiens, and have as keen an awareness of what they are earning as the rest of us, but if there were not a measure of idealism mixed in, why would they have chosen to make a career out of healing the sick?
The way in which the Quality and Outcomes Framework operates may seem a technical matter for health professionals, but is really of great significance for patients. Ninety-five per cent of medical problems are dealt with by GPs. The way in which we view the standard of health care that is available to us is therefore closely related to the sort of treatment we receive when we visit our GP’s surgery. We all know that doctors have to earn a living like everyone else, but at the same time we are always hoping, as we face our GPs in the consulting room, that they are putting our welfare first.
Robert Whelan
Deputy Director, Civitas
Related Stories...
Practice Vacancies
Locum and SGPs 
home