Published 4 June 2009, doi:10.1136/bmj.b2263
Cite this as: BMJ 2009;338:b2263

Editor's Choice

QOF and whistleblowers

This week Chris Ham (doi:10.1136/bmj.b2198) contrasts the UK Conservative party’s reliance on markets to improve performance with the "targets and terror" approach that has driven many of the recent improvements in the NHS. Many readers will like that description—though you probably also share Ham’s (familiar) concerns about the effectiveness of markets for health care.

Yet not all targets have been accompanied by terror: some have hefty incentives. None more so than the Quality and Outcomes Framework (QOF) in general practice, one of the most ambitious "pay for performance" systems in the world (BMJ 2003;326:457, doi:10.1136/bmj.326.7387.457). So far the verdict has been generally favourable—improved outcomes and little evidence of gaming. But one or two BMJ articles have begun to question the ability of a target setting payment system to be responsive enough to changing evidence and the subtleties of medical practice. For example, Lehman and Krumholz questioned why the targets for diabetes control were being tightened just as the evidence was suggesting that too tight control may not be such a good thing (BMJ 2009;338:b800, doi:10.1136/bmj.b800). And two other recent studies have cast doubt on some of the behaviours rewarded: Keenan et al, who questioned the usefulness of regular blood pressure monitoring (BMJ 2009;338:b1492, doi:10.1136/bmj.b1492), and Law et al, whose huge meta-analysis on blood pressure lowering suggests it might be better to lower blood pressure in everyone over a certain age, rather than measure it in everyone and treat it in some (BMJ 2009;338:b1665, doi:10.1136/bmj.b1665).

This week comes questioning of the QOF’s apparent success in improving the management of diabetes. Melanie Calvert and colleagues (doi:10.1136/bmj.b1870) studied changes in the quality of care for diabetes between 2001 and 2007 by following people with type 1 or 2 diabetes in 147 general practices across the UK. They observed improvements in process and intermediate clinical outcome measures throughout the six years, but they found that the improvement had started before the QOF was introduced and that improvements in clinical outcomes slackened off after 2005. They also found that the QOF case definition failed to capture up to two thirds of people with type 1 diabetes and a third of those with type 2 diabetes, and in general those outside the case definition did less well on target attainment. It would be hard on the basis of these studies to ditch such a comprehensive incentive scheme, but it’s clear the scheme’s not a substitute for professional responsibility and carefulness.

But speaking up for professional responsibility and carefulness isn’t always valued, as Peter Gooderham’s editorial on whistleblowing makes clear (doi:10.1136/bmj.b2090). "Most patients would surely expect doctors generally to protect them from potential harm," he says, yet despite a law designed to protect whistleblowers—and the insistence of ministers and professional regulators that whistleblowing is important—too often the result for whistleblowers is career destroying. Against a culture that encourages silence and the fear of speaking out, Gooderham suggests that a good start would be for those in official positions to recognise the risks of whistleblowing.

Cite this as: BMJ 2009;338:b2263

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