- A Niroshan Siriwardena, foundation professor in primary care
Strong primary care is a cost effective solution to better population health and reducing inequalities.1 The Quality and Outcomes Framework (QOF), the most comprehensive national primary care pay for performance scheme in the world, was introduced in 2004 to encourage evidence based practice and reduce variations in care for chronic conditions.2 It is a complex intervention comprising several elements including financial incentives, support for structured and team based care, and the pursuit of evidence based care.
There are early indications that the framework is associated with better recorded care, enhanced processes, improved intermediate outcomes,3 and reductions in inequalities4 and that it provides value for money in some but not all its clinical domains.5 It has helped consolidate evidence based methods for improving care by, among other things, increasing the use of computerisation, decision support, provider prompts, patient reminders (and recalls), skill mix, and teamwork.6 Many of these features were introduced before the framework but continue to be strengthened as a result of it. We should concentrate on addressing the criticisms rather than throwing away the gains.
What to measure
The indicators were developed from guidance or consensus, and even critics acknowledge that many are based on sound evidence.7 However, action is needed on indicators for which evidence is poor, or when evidence changes, and the involvement of the National Institute for Health and Clinical Excellence (NICE) should support this.8 There will always be a fine judgment about timing, level of evidence required, and whether to accept a consensus rather than evidence based indicator. An argument for greater consistency of care should not prevail where evidence is lacking: when there is uncertainty about the best treatment option a flexible approach to management is needed.
Effects are real
Quality of care has improved for some clinical areas since the framework was introduced.9 Although it is true that benefits have been small, these cannot simply be an effect of better recording because gains have also been reported in clinical domains that are not included in the framework.10 Some commentators have argued that care would have continued to improve along secular trends for long term conditions such as asthma, diabetes, or cardiovascular disease where initiatives already existed, but there have even been modest improvements above the trend in these areas9 11 as well as considerable improvements for epilepsy, which became a focus after the framework was introduced.12
Although care of clinical conditions not included in the framework has not improved, there has not been the worsening that some predicted.13 The framework was not designed to reduce health inequalities from socioeconomic disadvantage and it is unlikely to do so. Despite this, inequalities of care between the most and least deprived areas have narrowed,4 perhaps because the framework encourages greater consistency of care irrespective of deprivation.
Gaming is known to occur in many systems that are driven by pay for performance. However, there has been little evidence of gaming in the framework despite, or perhaps because of, a rigorous system of checks at various levels.14 On the contrary, practices are exceeding the upper payment thresholds15 and levels of exception reporting continue to fall year on year.16 Nevertheless, vigilance and systems to detect and prevent gaming are needed.
Finally, critics argue that the framework is turning general practitioners into unthinking automatons pursuing money at the expense of good patient care. Fortunately, most thinking GPs realise that high quality care is not synonymous with either achieving framework thresholds or practice profits; they are not motivated solely by money but rather aim to provide the best care for their patients.17 The balance of fixed versus performance related funding may be wrong. In fact, there is evidence that the structural changes to practice systems may have led to similar outcomes but with lower levels of incentive.17
Many GPs are concerned about the unintended consequences—that the framework might adversely affect care by reducing time for patients, failing to address patients’ concerns, or impairing continuity of care.6 A background of specialty training, years of experience, and embedded ethical practice have led most GPs to try to integrate the complex organisational demands of the framework into their current work by investing in staff, developing teamwork, and reorganisation aligned to improving reliability of care.18 19 Despite the added administrative pressures most GPs are endeavouring to provide holistic care, by integrating vertical systems of disease management into horizontal coordinated care for their patients.20
The framework is by no means a perfect system for improving quality—it needs to be improved and modified based on careful analysis of its effects, both intended and unintended, and the ever changing evidence that underpins it. Indicators with poor evidence should be removed, some for which performance has reached a ceiling may need to be retired,21 and new indicators should be introduced after piloting.22 A finessed approach at improving the framework rather than a premature attempt at abandonment is needed.
Cite this as: BMJ 2010;340:c2794
I thank Martin Marshall for his comments.
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that they have (1) no financial support for the submitted work from anyone other than their employer; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; and (4) NS is an academic (salaried, non-profit sharing) GP. He is editor of Quality in Primary Care.
Provenance and peer review: Commissioned; not externally peer reviewed.