Can QOF reflect true patient outcomes?

A recent NHS report on the QOF included a revealing line about its link to real patient outcomes: 'QOF has one true outcome-based indicator.'

Professor Lester: QOF should better reflect the art of being a GP (Photograph: P Hill)
Professor Lester: QOF should better reflect the art of being a GP (Photograph: P Hill)

The report went on to say that just 12 out of 86 clinical indicators measure 'intermediate' outcomes, and even these are a means to an end. Instead, the QOF is dominated by process measures and registers, which make up 518 out of the 697 clinical points available.

The reality is that, despite its name, less than a fifth of the 'quality and outcomes framework' is based on anything resembling a patient outcome.

Before entering government, ministers pledged to make the QOF more outcomes-focused. Members of NICE's QOF advisory committee acknowledge this is where QOF should be moving.

University of Birmingham researchers now believe they are close to solving the long-standing problem of how to create an incentive scheme with outcomes-focused goals that does not lead to unfair cuts in GP income. This is a key moment for the QOF, which many argue fails to effectively boost patient care in its current form.

Tick-box 'hysteria'
In February, RCGP chairwoman Dr Clare Gerada said the QOF had created tick-box 'hysteria', arguing it 'focuses GPs into the consultation room and not outwards into the community'.

Obesity campaigner and Hertfordshire GP Dr David Haslam believes QOF 'incentivises GPs to register obese patients and weigh them again the next year to ensure they still qualify'. 'There are no incentives for inducing weight loss,' he argues.

The Birmingham University team think they can improve the QOF by replacing current indicators with 'tightly linked measures' (TLMs). These are flexible, patient-centred and sensitive to the severity of a patient's condition.

Birmingham GP Professor Helen Lester leads the work and says TLMs are 'a much better way of looking at quality improvement in primary care than simple outcome measures'.

'We have to walk along a path towards outcomes, but in a way that makes sense and does not demotivate people,' she says.

Measurement criteria
Instead of having one criterion and one target, as many current indicators do, a TLM has a number of 'activating' criteria. GPs can then use clinical judgment to decide which target is most applicable and avoid over-treatment.

But TLMs do not punish GPs for failing to hit one strict target in patients with a more difficult starting point.

Professor Lester says the system 'rewards GPs for the right action'. 'If a GP has a patient group in a more deprived area, or where levels are harder to control, it does not penalise GPs if they do the right thing clinically even if the target is not achieved,' she says.

The researchers are piloting one TLM indicator for cholesterol in patients with diabetes at 34 practices in England, with results expected in June. Introducing TLMs could also reduce exception reporting and avoid penalising practices in deprived areas for low achievement.

They may also help dispel concerns over the effects of aggressive therapy to hit ambitious targets. But ensuring the complex data required can be easily extracted from GP computer systems will be the main challenge.

TLMs may be a compromise between protecting GP income and delivering better outcomes: ensuring that GPs can spend more time thinking about patients, not boxes to tick.

Professor Lester is adamant that QOF must evolve to survive. 'In 2004, it was world-leading, but now other countries are catching up, learning from our experience and introducing innovations of their own,' she says. 'We have to be brave if we want to move the QOF forwards and continue to improve patient care.'

Hopefully, she says, TLMs can do this and help QOF reflect all the subtleties inherent in patient care.

'TLMs better reflect the art of being a GP,' she says.

TLM example for BP

Points would be achieved when any one or more of these criteria are met:

  • BP is <150/90mmHg.
  • Patient is on three or more moderate-dose BP medicines.
  • Appropriate clinical action is taken within 90 days (for example, increase in medication dose, start a new medication, or repeat BP is <150/90mmHg).

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