Should the Quality and Outcomes Framework be abolished? Yes
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2710 (Published 07 June 2010) Cite this as: BMJ 2010;340:c2710
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The Quality and Outcomes Framework (QOF) should not be abolished but
should be subject to a major overhaul as part of the UK Coalition
Government's promised review of the GP contract. More focus needs to be
given to outcomes.
For example, 29% (£6.6M) of all the readily identifiable spend on
tobacco control in the Yorkshire and Humber region goes on QOF payments.
It is very difficult to quantify the return we get for this investment.
Indeed additional payments through a Locally Enhanced Service equating to
5.6% (£1.3M) of tobacco spend has had to be paid to practices to secure
targets for smoking quits verified at 4 weeks.
The addition of enhanced service agreements to try and get out of the
QOF what we need only adds to the bureaucracy and management cost of the
contract. It creates health inequalities as practices can choose whether
or not to participate.
So let's make QOF and Outcomes Framework. Give GPs an amount of money
within their contract to improve locally agreed outcomes and hold them
accountable. Cut the red tape and let primary care teams get on with doing
what they want to do - improving the health of their patients.
Competing interests:
None declared
Competing interests: No competing interests
One positive aspect of QOF has been the entrepreneurial spirit that
has resulted in on screen prompts in GP computer record systems. Amongst
these prompts are some reminders that can benefit patients, but
unfortunately the useful things can be obscured by the 'white noise'
created by interwoven mindless data collection prompts and prompts
designed to satisfy management and political imperatives.
This is illustrative of the problem with QOF as a whole: It has the
feel of an employee surveillance system, the philosophy underpinning it
being an apparent absolute necessity for inherent mistrust between
healthcare management and doctors.
Some QOF type indicators could actually benefit patients, doctors and
the wider healthcare system if there was a disconnect between the clinical
and financial/management controls. It would be better if financial and
management imperatives were satisfied by some form of alternative global
assessment of practices, rather than the current process which goes right
to the heart of the individual patient-doctor interaction within every
consultation. A radical change is required to produce the 'high trust low
bureaucracy' contract that was the original but now utterly absurd promise
of the new GP contract.
Competing interests:
None declared
Competing interests: No competing interests
Curate's Egg
There is one major advantage to the QuOF framework, and that is the
dissemination of state of the art treatment throughout the NHS primary
care
service. You can now walk into a surgery anywhere in the country and get
treated according to an internationally agreed standard. This is a
remarkable
achievement, and one which has not been given the credit it deserves.
It has, however, come at a price. The computer has now become the third
person in the consultation, and eats up a significant part of the doctor's
already limited consultation time. Secondly, the system is far too rigid.
The
need to get the numbers right means that patients find themselves taking
more and more medication, and I speak from personal experience.
Third,
although the system was designed to improve patient care, I wonder if it
is
not having the opposite effect. A reasonably computer literate seventeen
year
old could now give a passable imitation of a doctor if computer records
were
all that people go by. And the good doctor who keeps forgetting to fill in
the
various boxes will judged inferior to the dangerous or unpleasant doctor
who
keeps his frameworks in pristine condition.
There are two other drawbacks to the system. I cannot help but feel that
the
process is deskilling doctors, and that we are losing the some of the
subtleties of that most elusive of subjects, general practice medicine. I
also
have a feeling that patients are finding the NHS an increasingly
impersonal
place, and that the goodwill which patients felt to their local practices
is
diminishing as doctors become increasingly remote, and wealthy, figures. A
minor point, perhaps, but the goodwill of your patients is not something
to
be cast away lightly.
Competing interests:
In a QuOF group.
Competing interests: No competing interests