Chris Lancelot on...The complexity of quality

It’s that time of year again — the first cuckoo of spring is drowned out by a million ringing telephones as practices contact infrequent attenders to discover their smoking habits and push up their quality framework scores.

The quality framework rules — always complex — have become even more byzantine with the introduction of the extra targets. Their worst aspect is the treatment of empty registers. You lose points if you have no new cerebral vascular accidents, or no terminal care patients still alive, or if all your mental health patients turn up for their assessments.

Despite the quality framework being a national incentive scheme, practices also lose out if their community psychiatric services choose to be in charge of neuroleptic injections, or the local psychiatrists won’t use lithium. In turn this reduces your holistic score.

To add insult to injury, the loss of points from empty registers also drops the practice’s quality ranking in the eyes of the public. While I appreciate the primary care organisation argument — ‘If you’ve not done the work you don’t deserve the remuneration’ — it is wholly unfair to use raw quality framework scores to rank practices when some are barred from earning the points in the first place.

This demonstrates the important statistical principle of never using data collected for one purpose (in this case, payment for work performed) for another (practice ranking). Quality points should be allowable for empty registers, and practices’ scores should be released to the public as a percentage of available points, rather than as a raw figure.

The framework also forces us into potentially dangerous record-keeping. Practices routinely have to manipulate their coding to fit quality framework requirements — for example, entering ‘asthma resolved’ to remove a patient from the asthma register once they have COPD. How many medicolegal problems are we storing up for ourselves through being forced to fall in line with these rules?

One solution is for the DoH to introduce a set of Read codes exclusively for quality framework purposes. Until then, practices should consider adding ‘Entered for quality framework purposes only’ as free text against any clinically dubious entries. It might just save a trip to the GMC.

Dr Lancelot is a GP from Lancashire. Email him at

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