From the Trainer
Assistant Director (GP), South East Scotland
E-mail: judith.richardson{at}nes.scot.nhs.uk
General Practice like many things in life, has an annual cycle and for General Medical Services (GMS) Practices, we are in a particularly busy administrative phase as we approach year-end. For those of you based in practice, you will have observed both clinical and non-clinical staff glued to their computers muttering about points. Some of you may be wondering if this is something to do with booking summer holidays and collecting supermarket points for air miles, but no, it is the Quality and Outcomes Framework or QOF in short.
Since April 2004, QOF points make up a significant proportion of most practices income and as a result some GPs have become obsessed by collecting them. Another article in this issue of InnovAiT describes the nuts and bolts of the QOF in more detail.
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The QOF has also become of interest to newspapers as the number of points each practice achieves is in the public domain and inevitably results in a ‘league table’ of GP practices being produced by the media, closely linked to attention grabbing headlines of how much GPs earn! As with any league table, the headline figures do not necessarily reflect the quality of the practice under scrutiny and the figures are often used to cast doubt on the lower scoring practices which then find themselves having to defend their ‘achievements’. A recent headline in the free publication GP (30 November 2007) shouted PCT-run practices have 14% lower quality scores; you wonder how this makes the staff and patients at these practices feel? As the PCT spokespeople pointed out, there were many reasons why these practices scored below average including ‘specialised caseloads’ and ‘that because PCT-employed staff were not paid on the basis of delivering quality scores, they were less likely to exception report patients’. Certainly, the use and possible abuse of exception reporting has also been highly publicized over the past year with a report by the Centre for Health Economics (Gravelle et al., 2007) leading to headlines about ‘gaming’ and the subsequent calls for tighter control on or abolition of exception reporting. As a consequence of these acquisitions, many GPs feel they are being demonized for achieving quality patient care.
There is a lively debate around whether the QOF is improving patient care or indeed harming it as can be seen by a recent analysis article in the BMJ (Heath et al., 2007) ‘Measuring performance and missing the point?’ and the subsequent rapid response to this. This was closely followed by the publication of the NPCRDC review (available from: www.npcrdc.ac.uk/Publications/QoF_spotlight.pdf)—’What should happen to the Quality and Outcomes Framework?’ which it has submitted to the Department of Health with 10 recommended changes to the scheme. Both of these publications make for interesting reading and would be a good material for either a tutorial or small group discussion. Perhaps you could set up a debate along the lines of ‘This house believes that the Quality and Outcomes Framework has improved patient care’ and select people to argue for and against the motion.
For those of you who are stimulated to look into this further, there are several online resources out there but one that I find particularly good is www.gpcontract.co.uk which has a great interactive map where you can see prevalence data for the UK and links to the four countries data sets, so you can find your own practice and see how they perform against others in the country. Perhaps once you have found out how your practice has been performing, you could have a tutorial with the practice manager on how your practice copes with the data collection for QOF, what criteria they use for exception reporting and, if they are not achieving full points, why this might be.
Sometimes Associate-in-Training find practice management issues a little dull; hopefully, you have found the issues that I have raised in relation to the QOF anything but dull. Indeed, it raises many ethical issues about performance-related pay, professionalism and, for some, the loss of the holistic approach to GP.
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Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: evidence from the quality and outcomes framework. CHE Research Paper (May 2007) 28.
Heath I, Hippisley-Cox J, Smeeth L. Measuring performance and missing the point? British Medical Journal (2007) 335:1075–1076.
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