Chris Lancelot: Why exception reporting in QOF is essential

The DoH is considering scrapping QOF exception reporting, following a report suggesting that some gaming has taken place, including one case of outright fraud.

The GP Record, by Fran Orford

Clearly, the gaming of QOF targets is unethical. But to use this evidence to justify the removal of exception coding altogether is both illogical and vindictive.

As we all know, real medicine is 'fuzzy'. Diagnoses aren't always clear-cut; nor is treatment. Crucially, imposing simplistic targets does not make this fuzziness go away: QOF targets are often arbitrary or rounded values. (Why should BP in diabetes have to be 145/85 or lower? Why not 144/86?)

This fuzziness also includes medication. We all know patients whose BP can't be reduced without fainting or falls occurring. Similarly, patients may have an excellent clinical response to lithium despite having less than the recommended blood levels. Then there is patient suitability - for example, those dying of cancer, for whom fasting blood tests for cholesterol are inappropriate; or residents in elderly mentally infirm units whose co-operation with blood tests or medication is minimal.

Lastly, there is patient choice. Why should a practice be penalised if it cares for those who choose not to be immunised, or won't look after their diabetes? Good clinical medicine deals with all these issues - often by a deliberate, clinical decision not to treat, or else to treat to a different target. It is clearly wrong to penalise GPs who conscientiously work in this way.

Unfortunately, certain managers think exception coding is how practices evade criticism of their clinical care. Some PCTs even give a red rating on their practice scorecards for higher levels of exception coding. How simplistic. Which practice gives better care - one that gets 70 per cent of patients to target, but doesn't bother with the rest; or the practice that sees all of them, gets 70 per cent to target and correctly excepts the other 30 per cent?

Just because some GPs may have gamed QOF targets doesn't mean the rest of us should be penalised. If gaming is occurring then the DoH needs to attack the gaming, not the exception coding itself.

In the fuzzy world of medicine, if practices are to be remunerated for hitting targets then exception reporting is essential.

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