Gary Jones and Stuart Carroll: GPs' pay should be linked to patient outcomes

Gary Jones is a member of the Bow Group Health Policy Committee which is chaired by Stuart Carroll, a senior health economist and Policy Analyst. Here they summarise the research paper they have written with Jennifer White for the Bow Group on the Quality and Outcomes Framework (QOF), which is published today and can be downloaded here.

Launching the recent Conservative Draft Health Manifesto, Shadow Health Secretary Andrew Lansley recognised the current problems in the NHS, noting that under Labour, health inequalities have widened and public health problems, such as obesity and alcohol abuse, are increasing at soaring rates. The role of GPs in tackling these problems must not be underestimated. GPs are normally the first point of medical contact within the NHS and they play a vital role in preventive care, which typically involves diagnostic screening and providing advice on how to lead a healthy lifestyle.

A key part of Labour’s vision has been to empower GPs to improve both patient health outcomes and tackle inequalities. One of the key mechanisms for this vision was the Quality and Outcomes Framework (QOF) – a voluntary incentive scheme for GP practices in the UK that rewards doctors based on the quality of care delivered to patients. The QOF was launched in April 2004 and under this framework GPs are rewarded for implementing "good practice" in their surgeries. The framework is designed to remunerate general practices for providing good quality care to their patients and to help fund work to further improve the quality of health care delivered. 

In our research published today, we evaluate the progress the QOF has made since its introduction and consider the different ways in which the QOF can be reformed to be more effective.  Overall, it is fair to say that the QOF has been a relative success in supporting the drive to increase the standard of care, but there is strong evidence that standards have tailed off in recent years.

We have found that the problems and shortcomings currently informing the QOF are not so much a consequence of its philosophical purpose, but rather the practical elements determining its operational functioning. We believe that a key consideration for policymakers moving forward should be to look at how the QOF can be improved and reformed to better achieve its stated objectives.  Although the QOF in itself is not a vote-winner and is unlikely to register on the public’s political radar, it has the potential to facilitate the outcomes-driven health service the public wants to see and in turn is a potentially important piece of the NHS jigsaw.

One of the major problems of QOF is that perversely for a framework that claims to be about quality and outcomes it is so operationally geared towards emphasising process and targets. For example under the current system too much weight is placed on identifying smokers at the expense of incentivising GPs to stop patients smoking. In order to drive up standards, there is an urgent need for a greater emphasis on outcomes indicators over process.  Although there is a clear role for process measures in supporting the foundations of the QOF, there is a real danger that a lack of focus on outcomes can drive down standards and result in perverse incentives for healthcare professionals and in turn unintended outcomes.

It is also clear that despite the government’s intentions, a considerable gap remains between best achievable practice and the quality of care actually being provided on the ground. To a large extent, this is a direct consequence of the government’s continued obsession with process driven targets at the expense of emphasising patient health outcomes.   Focusing the QOF around clinical outcomes will help to address this unacceptable quality gap by rewarding practices that ensure patients receive the care they need to maintain their health; prevent the onset of diseases and provide more accurate diagnosis.

In addition, whilst over recent years there has been a major improvement in the health of the nation, this improvement has been much more dramatic among those living in wealthier areas. QOF’s performance in reducing health inequalities has been at best mixed and at worst disappointing. Under the QOF, GPs working in inner-city areas may feel they have to work much harder, and invest more practice resources, to perform well against outcome-based quality targets. In order to counter this, the QOF should be reformed to contain an appropriate incentives structure to support GPs working in deprived areas.

It is widely recognised that for the NHS to be a genuinely patient-centred healthcare system, there needs to be a greater degree of flexibility for local commissioners and healthcare providers. Yet the setting of QOF targets is determined at the national and central level. It is from this perspective that we believe Primary Care Trusts (PCTs) should be granted the flexibility to vary some indicators from practice to practice. For example, in those areas where there is a high prevalence of obesity it would seem sensible to trial local targets to try to counter this health problem.

Using expert interviews with GPs and other stakeholders, other key findings from our report include:

• Instead of rewarding GPs for recording smoking rates, the QOF should be incentivising GP activity around monitoring and promoting smoking cessation rates.
• Although there was a recent addition of 8 points within the QOF for setting up an obesity register, in reality this is likely to have a limited impact in dealing with the patient’s underlying condition and improving long-term outcomes.  It is from this premise that the framework requires urgent revision and attendant reform.
• Whilst there are a number of practical difficulties in measuring and rewarding improvements in public health, the government should urgently review the proportion of the framework which is geared towards prevention and public health.  
• We call on the government for alcohol abuse and consumption to be firmly embedded in the QOF, and to form part of a wider preventative healthcare strategy throughout primary care.
• In order to improve the way the QOF works, there is a need for greater joined up working with local communities. QOF reports should also be made accessible to the public.
• A major and recurring concern with the QOF has been the real impact on those conditions currently not included within the existing framework.  
• We recommend that vaccines, pharmacy and pain are included in a renewed and revamped QOF. 

While the Conservatives have rightly concluded that the QOF needs to be “unpicked”, they have been less clear on how it would be restitched.   Although we make no claim that our paper constitutes the fully stocked haberdashery store, we believe it contains some of the key sewing notions and small wares to truly place quality and outcomes at the heart of the QOF.  Let outcomes, a greater emphasis on public health, and more integrated working be the future of the QOF.  By doing so, the QOF’s own value and future might just be restored.