GP leaders and health officials are set to clash over plans to introduce local quality framework (QOF) indicators in 2010, after responses to a DoH consultation revealed a yawning gap between their views.
The GPC and the RCGP believe that local indicators will undermine the uniform patient care achieved through a national approach. Local priorities should be tackled through local enhanced services (LESs), they argue.
But the DoH and the NHS Confederation want local flexibility in the framework, as does the Royal College of Nursing.
The DoH has suggested that local indicators would only form a small percentage of the framework. But others, such as the NHS Confederation, say the majority should be determined locally, with only a small national core QOF.
The DoH says local flexibility could 'help PCTs address particular health needs within local populations'.
National health priorities
GP leaders, however, believe the move is 'misguided'. GPC chairman Dr Laurence Buckman says: 'We cannot understand how evidence that applies in one part of the country would not apply in another part.'
The GPC rejects the notion that health priorities differ across regional and national boundaries.
Its response to the DoH consultation says: 'The care required by individual patients does not, and should not, depend on where a patient lives. We consider that, on this basis, the concept of a local QOF cannot be supported.'
GPC and RCGP leaders point out that the GMS contract already allows local variation.
The contract states that enhanced services can include 'services addressing specific local health needs', the GPC points out. 'Any existing local priorities should be funded through the existing contractual mechanism of LESs.'
But the DoH suggests that the development of services focused on local health needs is currently limited by a number of factors, which local quality indicators would be able to work around.
For instance, PCTs do not have the expertise needed to develop evidence-based indicators and local IT systems cannot easily extract data from clinical systems and link it to payment information.
The DoH suggests that these problems could be overcome if PCTs could negotiate locally over QOF targets from a menu of indicators reviewed by NICE.
This view is echoed by David Stout, director of the NHS Confederation's PCT network. He says that a national menu of QOF options would be 'less reliant on local PCT expertise than the development of effective LESs.'
But if the key concern is taking responsibility for developing enhanced services off PCTs' hands, the GMS contract arguably has this covered. National enhanced services offer a range of off-the-peg services - deals agreed at a national level - that PCTs can choose to adopt to suit the needs of their populations.
But PCTs have often failed to invest in enhanced services. The DoH appears to have decided that letting PCTs tap into QOF funding may finally get them to innovate.
The DoH argues that allowing some of the £1 billion national investment in QOF to be set aside to fund local indicators would make the introduction of local variation 'more practical'.
The GPC says national QOF funding should not be cut.
Dr Buckman says the decision to give PCTs the option for local variation seems a fait accompli. 'The way that the consultation is worded makes it sound as if the government has already made up its mind,' he says.
Even so, there is no guarantee local QOFs will materialise. Dr Buckman does not think PCTs are any more likely to introduce local indicators than they have been to commission LESs.
Dr Stout also acknowledges that uptake of local QOF indicators will vary. 'Some PCTs in the consultation were more keen on this idea than others, so the usage would probably not be uniform,' he says.
The DoH says that any decision to introduce local QOFs would be subject to consultation with the GPC.
The GPC has pledged to fight its corner, however. 'We have absolutely no interest in locally enhanced QOFs,' Dr Buckman says.
How NHS organisations responded to the QoF consultation
- DoH Greater local flexibility would help PCTs invest resources in ways that best meet the health needs of their local population. (Health secretary, Alan Johnson)
- NHS Confederation A small national core QOF would allow the maximum resource for PCTs to invest in services that meet local needs. (Left: PCT network chairman, David Stout)
- RCN The RCN supports appropriate local decision-making, and reserving an element of funding to finance locally relevant indicators. (General secretary, Peter Carter)
- GPC We have serious concerns that fragmentation of a national QOF into a set of local priorities will be detrimental to the already reduced gap in health inequalities. (Left: chairman, Dr Laurence Buckman)
- RCGP Local priorities should be funded through the existing mechanism of local enhanced services. A national QOF, with LESs, acts as a guarantor of consistent quality in patient care across the country. (Chairman, Dr Steve Field)
Comment below and tell us what you think