Views & Reviews From the Frontline

Kill the QOF

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1498 (Published 06 March 2013) Cite this as: BMJ 2013;346:f1498
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}yahoo.co.uk

We are entering the 10th year of the world’s largest public health experiment in evidenced based medicine—the target driven QOF (Quality and Outcomes Framework). It has cost £10bn in direct payments to general practitioners,1 but this is just the tip of an expensive iceberg. Hidden are the appointments systems overloaded with arbitrary “reviews” and huge increases in investigations and prescribing. Once highly functional general practice computing systems are now clogged with constant pop-up reminders to enter data that are meaningless, useless, and frankly often erroneous. GPs now gaze on a computer, not the patient. A once simple, lean, and agile primary care has been made bloated and overcomplicated. No discretion, no judgment; this is flow chart medicine and a profession left in a persistent vegetative intellectual state. The QOF apologists trot out the “recorded” reductions in blood sugar, blood pressure, and the like, but these are mere soft surrogates.

What of hard endpoints? From 2004 to 2011 prescriptions for statins doubled, for angiotensin converting enzyme inhibitors and diabetic drugs near doubled, for antidepressants rose 60%, and for steroid inhalers rose 30%.2 Polypharmacy is the norm not the exception, and research evidence validates this approach. Yet statins, for instance, are supposed to reduce heart disease by 30% within a few years.3 The QOF has created three million new statin users,2 so why has there been no demonstrable effect on heart disease trends?4 Also we might reasonably expect within a decade to see a change in the trajectory of UK life expectancy, but we have not.5 Likewise the QOF was designed to improve chronic disease management in general practice, but instead outpatient referrals have risen 5% annually,6 with similar rates in acute hospital admissions.6 This is leading to unsustainable pressure and costs throughout the NHS. Perhaps assessing the impact of QOF is impossible because there is no control group. But we can compare UK trends with other similar countries, and there is no evidence that UK healthcare is outpacing these countries.

The QOF simply hasn’t worked. It is a bureaucratic disaster, measuring the measurable but eroding the all important immeasurable, and squandering our time, effort, and money. It has made patients of us all and turned skilled clinicians into bean counters. Incentives and centralised targets are under scrutiny throughout the public sector because targets just lead to gaming. It’s time to look away from the screen and at the patient once again. Turn off the financial life support and let this failed intervention die.

Notes

Cite this as: BMJ 2013;346:f1498

Footnotes

References