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NEWS: Andrew Cole UK GP activity exceeds expectations BMJ 2005; 331: 536 [Full text]

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Quality and Outcomes Frameworks and the overall burden of disease

Peter M Lapsley   (9 September 2005)

GPs have done well, but is care equitable?

Mark Strong   (9 September 2005)

Quality and Outcomes Frameworks and the overall burden of disease 9 September 2005
Peter M Lapsley, Chief Executive Skin Care Campaign, Hill House, Highgate Hill, London N19 5NA Send response to journal: Re: Quality and Outcomes Frameworks and the overall burden of disease	Editor In his news article, UK GP activity exceeds expectations (BMJ 2005:536, doi:10.1136/bmj.331.7516.536), Andrew Cole asserts that the health department’s findings show hypertension, asthma, coronary heart disease and diabetes to be the most common chronic conditions. They do not. All they show is that these conditions are the most common amongst those for which Quality and Outcomes Frameworks (QOF) are included in the new GP contract. Although about 15% of GP consultations relate to skin disease [1], and although many chronic inflammatory skin diseases including acne, eczema and psoriasis can result in disability levels equivalent to those experienced by patients with non-dermatological diseases such as angina, arthritis, asthma, cancer, diabetes and epilepsy [2] [3] [4], skin diseases are excluded from the contract’s QOF. In Britain, the average medical undergraduate curriculum includes only six days of dermatology and there is no structured educational programme in dermatology for nurses [5]. In consequence, the diagnosis, treatment and management of skin diseases in primary care is patchy and generally sub-optimal. The omission of skin diseases from the contract’s QOF exacerbates this. Understandably, GP practices tend to focus upon those areas of their work that attract additional funding at the expense of those that do not. If there are to be QOF in the contract, they must reflect the overall burden of disease seen in primary care and must therefore, by definition, include skin disease. 1. Williams HC. Increasing demand for dermatological services: how much is needed? J R Coll Physicians Lond 1997; 31: 261-2. 2. Harlow D, Poyner T, Finlay A Y, Dykes P J. Impaired quality of life of adults with skin disease in primary care. British Journal of Dermatology 2000; 143: :979-982 3. Mallon EM, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999;140:672-6. 4. Rapp SR, Feldman SR, Exum ML et al. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol. 1999 Sep;41(3 Pt 1):401-7 5. All Party Parliamentary Group on Skin Report on Dermatological Training for Health Professionals, London 2004 References added 13.9.05
GPs have done well, but is care equitable? 9 September 2005
Mark Strong, Specialist Registrar in Public Health Medicine Rotherham Primary Care Trust, Oak House, Rotherham, S66 1YY, UK Send response to journal: Re: GPs have done well, but is care equitable?	UK GPs have done well out of the Quality and Outcomes Framework (QOF), earning close to £630 million by achieving an average of 91% of the possible 1050 points.[1] This is good news for patients too if we assume that the QOF measures the extent to which high quality care is provided, but have all patients benefited equally? It has long been appreciated that those most in need of good quality health care receive the poorest service – the Inverse Care Law.[2] Will this Law continue to apply in the era of QOF, or are the new financial incentives so strong as to abolish any potential inequity? Our analysis of the 2004-5 English QOF data suggests that while practice level achievement varies (median 1000 points, interquartile range 939 to 1033), only 4% of this variation is explained by the variation in practice deprivation (linear regression model with deprivation defined as the Index of Multiple Deprivation (IMD) score of the Super Output Area in which the practice resides).[3,4] At PCT level the picture is somewhat different. The aggregated achievement again varies (median 979 points, interquartile range 945 to 1005), but at this level deprivation explains 33% of the variation (linear regression model with deprivation defined as the population weighted mean IMD scores of the census output areas mapped to PCT boundaries).[5] The poor correlation between achievement and deprivation at a practice level suggests that the QOF has at least ensured that many patients in deprived areas are receiving high quality care, and this is good news. However, it appears that systematic inequities still exist at a PCT level and attempts should be made to address this. References 1. Cole A. UK GP activity exceeds expectations. BMJ 2005;331:536 2. Hart, JT. The Inverse care law. Lancet 1971;1(7696):405-12 3. Noble M, Wright G, Dibben C, Smith GAN, McLennan D, Anttila C, et al. The English Indices of Deprivation 2004 (revised). London: Office of the Deputy Prime Minister, 2004. http://www.odpm.gov.uk/stellent/groups/odpm_urbanpolicy/documents/page/odpm_urbpol_029534.pdf (accessed 7 July 2005). 4. Health and Social Care Information Centre. 2004/05 QOF data. http://www.ic.nhs.uk/services/qof/data/ (accessed 9 Sept 2005) 5. The Healthcare Commission. Primary Care Trust level Index of Multiple Deprivation 2004. Jan 2005. http://www.erpho.org.uk/download.asp?id=11439&typeID=2 (accessed 9 Sept 2005) Competing interests: None declared