The QOF has brought benefits to GPs but greater rewards will depend on creating a culture of sharing, says Dr Jill Murie
In May this year, many people were anxious to find out how their local practices had performed during the first year of the Quality and Outcomes Framework (QOF).The editor of our local paper was no exception.
“Doctor hits back at ‘league table’ claims” ran a headline that described the reaction of one single-handed GP, whose 473 points placed him “worst” in Lanarkshire. He was at pains to explain that it was possible to provide good clinical care despite failing to achieve a high QOF score.
Ninth from bottom of the 100-practice ‘league’, with 780 points, was an eight-doctor practice with enviable new premises and modern IT systems. This is unusual, as larger practices operating in more affluent areas tend to score highly in the QOF. Some smaller practices in more deprived rural areas achieved more than 780 points.
The critical success factors for achieving maximum points are effective leadership, good infrastructure and well-run clinics that employ the right mix of skills. Other essentials are robust IT systems, training and access to community pharmacists and secondary care services. Above all, success in the QOF depends on a commitment shared by the whole primary care team.
During the first year, the more difficult clinical indicators have been those for which there were no pre-existing registers and no clear inclusion criteria, such as cancer and severe mental illness. These areas involved more work for less reward.
In some areas it has proved difficult to establish accurate disease registers. For example in the epilepsy indicators, a search for patients on anticonvulsants includes those taking the medication for neuropathic pain or a psychiatric disorder. All indicators have depended for success on practice lists being highly accurate.
The improvements in care arising from the QOF are likely to be reflected in a continued downward trend in second myocardial infarctions and better identification of patients with diabetes. Disease registers are the first step in reducing the complications of diabetes through improved management of glycaemia and microalbuminuria, and through retinal screening.
The QOF still has teething problems, however. Prevalence data vary widely, particularly for hypertension, asthma and epilepsy, creating difficulties in calculating practice income using the prevalence factor formula. GPs often need to use exception reporting to achieve close to 100% of the points in any indicator. However, evidence suggests that it may not always be entirely legitimate to do so.
Primary care organisations have a statutory duty to improve the health of the population. However, they have no jurisdiction over practices with low scores, because participation in the QOF is ‘voluntary’. Instead, the PCO’s role is supportive, to facilitate maximum achievement.
The success of many practices in achieving near-maximum points demonstrates GPs’ ability to respond to the challenge of improving clinical outcomes. However, more effort is required to identify and address the needs of hard-to-reach groups, such as those with learning disabilities, dementia or severe mental illness. Opting out by exception reporting should be discouraged.
There is good reason to celebrate practices’ achievements during the first year of the new contract. It is now time to share innovative practice and maximise not just points but benefits in patient care.