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EDITORIALS: Helen Lester The UK quality and outcomes framework BMJ 2008; 337: a2095 [Full text]

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True, but not the whole story

James D Gubb   (29 October 2008)

QOF may narrow health inequalities but gaps in care persist for non-incentivised conditions

Jonathan R Bayly   (29 October 2008)

Goodharts Law and The Quality & Outcomes Framework

Nicholas Summerton   (22 November 2008)

Both soft and hard endpoints are important

Martin Roland   (24 November 2008)

True, but not the whole story 29 October 2008
James D Gubb, Director - Civitas Health Unit Civitas, SW1P 2EZ Send response to journal: Re: True, but not the whole story	Of course, this is all true. Since the introduction of the QOF, quality of care in terms of what it measures has undoubtedly improved across general practice - an improvement that has generally been over and above what went before (Campbell et al., 2007). One subsequent result has been that health inequalities on such measures have also fallen - as Ashworth et al. (2008) and Doran et al. (2008) document. Both are welcome developments, particularly when set against the historic picture of variation in general practice. GPs and auditors knowing at the touch of a button what proportion of diabetic patients have their HbA1c glucose levels controlled is a significant development on what went before. However, this is not the whole story. As the American statistician, W. Edwards Deming, once warned, 97 per cent of what is important either isn’t measured or isn’t measurable (Neave, 1990). We should always be aware of unintended consequences. Professor Lester documents a positive one - on health inequalities for measures in the framework - but there are others that fall down on the wrong side of the net and are not mentioned. Two of the most poignant are: First, on health inequalities. It is likely that equity in primary care falls into two categories: equality of care among patients (i.e. those who have accessed the service) and equality of care across the overall population, which includes access to the service, the incidence and prevalence of disease, and wider socioeconomic inequalities linked to health (Low and Low, 2006). The QOF cannot capture the latter adequately, because it refers only to particular conditions, says nothing of care in relation to need and is a post-access measure. In fact - as the BMA and NHS Employers have recently acknowledged - the QOF, through using an adjusted prevalence formula rather than true prevalence, has tended to systematically penalise those practices with high incidence of chronic disease; often those in deprived areas (Guthrie et al., 2006). This has had a detrimental effect on wider health inequalities outside the framework's scope. Second, quality in general practice of course includes clinical quality (or 'technical effectiveness'), but what is also vital is interpersonal quality (or 'effectiveness') (Donabedian, 1966; Campbell et al., 2000). This is not just what patients want (Cheraghi-Sobi, 2006), but also has many clinical benefits as well, such as the initial recognition of patients’ problems (that tends to be the rate-limiting step in quality of care), more accurate diagnosis, better concordance with treatment advice, more appropriate decisions about preventative behaviour, and less use of emergency services (Starfield, 2005). The QOF does not take such issues into account and - through the opportunity cost of time taken to get QOF points, and the 'second voice' this may put in the clinician's head - does risk crowding out the patient-centred and holistic benefits of general practice. Indeed, an analysis of an earlier pay-for- performance scheme in Scotland revealed just this (Howie, 1995); and there is emerging evidence with regard to the QOF (Campbell, S, et al., 2008). We should be concerned with a careful analysis of net benefit, not just looking at the QOF on its terms. Ashworth, M, et al., Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework, BMJ 2008;337:a2030 Campbell, S, et al., Defining quality of care, Soc Sci Med 2000; 51: 1611-1625 Campbell, S, et al., Quality of Primary Care in England with the Introduction of Pay for Performance, NEJM 2007;357;2 Campbell, S, et al., The Experience of Pay for Performance in English Family Practice: A Qualitative Study, Annals of Family Medicine, May/June 2008;6;3 Cheraghi-Sobi, S, et al., What are the key attributes of primary care for patients? Building a conceptual map of patient preferences, Health Expect 2006; 9(3): 275-284 Donabedian, A, Evaluating quality of care, part 2, Millbank Memo Fund Q 1966; 44:166-206 Doran, T, et al., Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework, The Lancet 2008; 372:728-736 Guthrie, B, et al., Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract, Br J Gen Pract, 2006; 56: 836–841 Howie J G R, et al., Care of patients with selected health problems in fundholding practices in Scotland in 1990 and 1992 : needs, process and outcome. Br J Gen Pract, 1995 45, 121-6 Low, A, and Low, A, The QOF equity window: an illusion or a different view?, J Public Health 2006 28(3):293-294 Neave, H, The Deming Dimension, SPC Press Inc., 1990 Starfield, B, et al., Contribution of primary care to health systems and health, Milbank Q, 2005;83:457-502 Competing interests: None declared
QOF may narrow health inequalities but gaps in care persist for non-incentivised conditions 29 October 2008
Jonathan R Bayly, Lecturer in osteoporosis and falls University of Derby, Keddleston Road, Derby, DE22 1GB, UK Send response to journal: Re: QOF may narrow health inequalities but gaps in care persist for non-incentivised conditions	It is encouraging to see QOF apparently delivering on reduced health inequalities (1) and may go some way to reducing the concerns expressed recently by NICE when considering whether to include specific ‘deprivation indicators’ in to the framework. Professor Lester in her editorial (2) maintains “that practices have delivered the same quality of care for conditions not included within a pay for performance scheme”. This rather reassuring statement hides the conclusions of the quoted paper by Steel and colleagues (3) where practices were found to have failed to deliver improvements in non- incentivised conditions and that those same patients may be at risk of poorer quality care. This appears to be particularly the experience of older people with long term conditions not in the framework (4). In no disease area is this more true than in the secondary prevention of fragility fractures. The Healthcare Commission in its annual health check (5) last week congratulated NHS Trusts on the leading improvements in the standards in the delivery of Core Standard 5a. 95% of Trusts now claim to be delivering NICE Technology Appraisals, including that referring to secondary fracture prevention. The very same body has commissioned a national audit of falls and bone health (6) and has been on the circulation list for a database study in 3.4 million patients in primary care (7) which together show that in fact 80-90% of patients with a fragility fracture fail to receive care documented in NICE Technology Appraisal Guidance. The consistent failure of the implementation of NICE guidance or the inclusion of indicators for secondary fracture prevention has resulted in virtually no improvement in the standards of care for this often elderly at risk population who are not good at advocating for their own needs and effectively creates a new health care divide. The recently announced Directed Enhanced Service, a pale apology for the submitted QOF indicators, will not adequately address this need as incentives drive care for patients for 12 months only. 1. Ashworth M, Medina J, Morgan M. Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework. BMJ 2008;337(oct28_2):a2030-. 2. Lester H. The UK quality and outcomes framework. BMJ 2008;337(oct28_2):a2095-. 3. Steel N, Maisey S, Clark A, Fleetcroft R, Howe A. Quality of clinical primary care and targeted incentive payments: an observational study. Br J Gen Pract 2007 57:449-54. 4. Steel N, Bachmann M, Maisey S, Shekelle P, Breeze E, Marmot M, et al. Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England. BMJ 2008;337(aug13_2):a957-. 5. Healthcare Commission. The annual health check 2007/08: A national overview of the performance of NHS trusts in England. 2008. 6. Clinical Effectiveness and Evaluation Unit. National Clinical Audit of Falls and Bone Health: Available from http://www.rcplondon.ac.uk/COLLEGE/ceeu/fbhop/fbhop-nationalreport.pdf) [Accessed 25 August 2008]. London, 2007. 7. Hippisley-Cox J, Bayly J, Potter J, Fenty J, Parker C. Evaluation of standards of care for osteoporosis and falls in primary care: The Health and Social Care Information Centre, 2007. Competing interests: Jonathan Bayly has received honoraria, travel and subsistence expenses from a number of companies with an interest in falls and bone health (Procter & Gamble, Roche, Novartis, Shire, Amgen, Pfizer, Strakan, Servier, Menarini)
Goodharts Law and The Quality & Outcomes Framework 22 November 2008
Nicholas Summerton, GP 7 Hall Walk, Welton, Brough. HU15 1PN Send response to journal: Re: Goodharts Law and The Quality & Outcomes Framework	Professor Charles Goodhart was Chief Advisor to the Bank of England. His `law` states that `when a measure becomes a target it ceases to become a good measure`. Helen Lester`s conclusion that Ashworth et al`s study of blood pressure demonstrates that the quality and outcomes framework has improved quality of care and reduced health inequalities is premature. There have certainly been improvments in practice income but I should now like to see that these are also translated into improvements in cardiovascular mortality and morbidity. Competing interests: None declared
Both soft and hard endpoints are important 24 November 2008
Martin Roland, Director, National Primary Care Research and Development Centre University of Mancheter, M13 9PL Send response to journal: Re: Both soft and hard endpoints are important	Spence (1) and Summerton (2) call for hard end points for the Quality and Outcomes Framework such as cardiovascular mortality. Other correspondents suggest that important but less measurable aspects of care have declined since the new GP contract. Soft endpoints are important, but so are hard ones. In recent years there has been a steady increase in UK life expectancy of around one additional year every five years (3), a reduction in cardiovascular mortality in men under 75 by 38% between 1998 and 2006 (4), and increased rates of cancer survival (5). These changes are no doubt due to a combination of societal factors and improvements in both primary and secondary care. In general practice there have been dramatic improvements in some aspects of clinical care since 1998 (6). Let us by all means have a debate about the cause of the improvements and about unintended consequences of new initatives. But let us not conduct the debate as if these major improvements in health were not real. They are likely to be attributable, at least in part, to changes in the way we deliver medical care. 1. Spence D. Lay your money down. BMJ 2008; 337: a2619 2. Summerton N. Goodharts Law and The Quality & Outcomes Framework. BMJ Rapid response http://www.bmj.com/cgi/eletters/337/oct28_2/a2095 3. Office for National Statistics. Life expectancy www.statistics.gov.uk/cci/nugget.asp?id=168 4. The Health Foundation. QQUIP (Quest for Quality and Improved Performance. Mortality from all Circulatory Disease. http://qquip.health.org.uk/qquip/index.aspx?chapterid=19486&contentid=21483&ContentTemplateID=2246 5. Office for National Statistics. Cancer survival 1999-2004 (www.statistics.gov.uk/cci/nugget.asp?id=861 6. Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. New England Journal of Medicine 2007; 357:181-190 Competing interests: The author advised on the development of the QOF in 2002 and 2003