Has QOF reached a dead end?

After 10 years, many believe QOF needs a major rethink. Stephen Robinson reports.

In the future, 2013 may be regarded as a watershed year for QOF, as calls grow for sweeping reform of the decade-old framework.

QOF's evolution has prompted GP anger over the growth of tick-box medicine, the bureaucratic burden on practices and the unmanageable rise in workload.

This culminated last month in GPC chairman Dr Chaand Nagpaul calling for the withdrawal of QOF targets that 'do not benefit patients'. Health secretary Jeremy Hunt has also admitted that changes may be needed.

Thresholds

It is only five months since QOF underwent a major overhaul. In came higher thresholds, reduced time to meet targets and a raft of NICE recommendations on clinical goals. Out went the organisational domain, trimming QOF by 10%. Now, more radical surgery is on the horizon.

GPC deputy chairman Dr Richard Vautrey recently told GP that QOF had become 'too much of a micromanagement tool'.

He said many GPs had doubts about the validity of newer QOF targets that did 'not feel appropriate'. The GP Physical Activity Questionnaire target for hypertension has been singled out in particular.

In June, a GP survey of 1,173 UK GPs found many were being forced to turn down new enhanced services and give up chasing QOF points because of 'overwhelming' workload from the imposed GP contract for 2013/14 (GP, 24 June).

GPs described how QOF had become 'ridiculous'. One said: 'QOF is out of control, we have reached our limit. It is interfering with proper patient care.'

The GPC is strengthening its position ahead of the autumn negotiations over the next GP contract by conducting its own workforce survey to quantify GP morale and workload. This will give negotiators evidence to put to the government as it presses for a better deal for GPs.

The negotiators could also point to recent studies casting doubt on whether QOF will meet the challenges facing primary care in future.

In July, a paper by UK researchers reported what many GPs have long suspected: that QOF has forced GPs to address a rigid biomedical agenda at the expense of patients' individual needs.

Lead author and Manchester GP Professor Carolyn Chew-Graham says QOF in its current form is not well suited to directing care for patients with multiple long-term conditions. 'QOF encourages diseases to be reviewed separately, so patients risk having to attend for a number of different reviews when they have multimorbidity,' she says.

She describes the withdrawal of depression case-finding among patients with diabetes and/or CHD from this year's QOF as a 'backward step', because depression and/or anxiety are comorbid with many long-term conditions.

Making the case for change

GPC chairman Dr Chaand Nagpaul

The GPC wants to

  • Withdraw QOF targets that do not benefit patients.
  • Remove bureaucratic and non evidence-based demands on GP time.
  • Scrap targets for annual GP Physical Activity Questionnaire checks for hypertension patients.
  • Reduce workload to manageable levels.
Health secretary Jeremy Hunt

The government says

  • QOF gets in the way of individualised care and proactively thinking about the needs of vulnerable patients.
  • Indicators could be stripped back to reverse target and box-ticking culture.
  • However, NHS England looks unlikely to agree radical changes to QOF in 2014.

Patient-centred care

Looking forward, longer consultation times could be a way to balance the demands of evidence-based and patient-centred care. Professor Chew-Graham says: 'There would be time for patients to voice concerns, as well as be subject to the demands of the computer template.' Another solution may be to limit QOF's impact on consultations by reducing its size.

Dr Nagpaul has said that while he would not call for QOF to be scrapped, it could be downsized, with more funding transferred to core pay. This view was shared by two members of the NICE QOF advisory committee in a BMJ paper published last February.

Bedfordshire GP Dr Stephen Gillam and University of East Anglia academic Dr Nicholas Steel argued that QOF makes up too large a proportion of practice income.

Research has shown no link between the size of financial incentives and the likely health gain from the incentivised activity. It means improvements delivered by QOF could have been achieved with smaller incentives, they said.

'Money should be taken out of QOF and redirected to supporting general practice in other ways,' they said. 'The downsides of QOF may remain with smaller incentives, but at least untied funding for general practices may help redress the imbalance it imposes.'

QOF expert and Wiltshire GP Dr Gavin Jamie agrees and says many of the premises on which QOF was introduced no longer apply. 'The introduction of QOF was largely driven by government, which wanted more information about how the NHS was spending the money,' he says.

'QOF yielded a lot of data about practices. At least nominally, this was the NHS's first bash at measuring and assessing quality in providers. We are in a very different situation now. The CQC and NHS England area teams are much more hands- on with practices.

'A huge amount of data is due to be sucked out of practice systems in the next couple of months under the Care.data scheme. From the commissioners' point of view, there may be much less point to QOF now.'

He says there is a feeling QOF has become 'a bit desperate' to find something to measure. The solution is to downsize and refocus, he argues. 'I would like to see a more focused QOF. Let's concentrate on some of the better-evidenced outcomes.'

Dr Jamie believes QOF should consist of just 300 points, although he warns the remaining funding must be retained in the global sum. 'If the cash is sent elsewhere and the requirements remain, quality practice may become unviable.'

Despite this year's contract imposition, there may be some common ground in talks between the GPC and the government.

Target culture

Health secretary Jeremy Hunt has signalled an intention to cut back on target culture that 'gets in the way of the personal relationship between doctor and patient' (GP, 5 August).

NHS England acknowledges that QOF must evolve and has invited GPs to respond to a consultation on the future of general practice and QOF. A spokeswoman told GP: 'NHS England is keen to find ways of reducing administrative burden in practices whilst maintaining the evident clinical benefits for patients achieved since QOF was introduced.'

NICE is considering how QOF can change and will review how thresholds for new indicators are set as part of a wider rethink on targets. A public consultation is due later in the year.

With QOF at the centre of GP anger over the contract, it will become a focal point for negotiations over next year's deal. By next spring, GPs could see - and many will hope for - a much changed QOF.

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