Should the Quality and Outcomes Framework be abolished? YesBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2710 (Published 07 June 2010) Cite this as: BMJ 2010;340:c2710
The impact of the Quality and Outcomes Framework (QOF) on general practice has, arguably, exceeded that of any other policy development since the Family Doctors’ Charter of 1966. A sensible verdict needs to balance a nuanced assessment of health and other gains against its costs, many of which are hard to describe let alone quantify. But I believe that the evidence supports its abolition.
The £1bn (€1.2bn; $1.4bn) a year that the scheme costs has yielded remarkably modest improvements in measured quality of care and only slight reductions in disparities between socioeconomic groups.1 2 In many cases, improvements in clinical indicators were in line with increases that might have been predicted on the basis of secular trends before the framework was introduced.
To what extent these improvements are the vicarious result of better recording remains unclear. What is clear is that commercially constructed evidence is driving up prescription rates for antidepressants, statins, and other drugs with little evidence of improvement in proxy outcomes.3
Incentives were not aligned to tackle inequalities in health, and other factors impair the framework’s impact at population level. Setting targets below 100% and the process of exception reporting (which allows patients to be excluded from performance figures) reduces the public health effectiveness of population targets by shifting the focus away from harder to reach patients. More fundamentally, payment for adhering to guidelines cannot be assumed to improve health status, regardless of whether it improves “performance.” The framework’s evidence base will only ever be partial.
With the entrepreneurial dynamism characteristic of UK general practice, teams have adapted swiftly to its imperatives, but core activities have been distorted around the framework. For many practices, clinical governance and audit have become synonymous with the framework. Quality of care is narrowly focused on domains and indicators included in the framework to the exclusion of other areas for practice development, innovation, and quality improvement. The framework promotes a mechanistic approach to managing chronic disease, reducing clinical practice to a series of dichotomised decisions. Both doctors and nurses are concerned about the “box ticking culture”: the intrusive impact of computerised templates that turn people into codes, to the detriment of person focused care.4
Although research has found little evidence of gaming, the corrosive cynicism that pay for performance engenders is almost more destructive. Last year my practice earned £289 for administering a second patient health questionnaire to each depressed patient; by comparison, recording blood pressure in a patient with known hypertension earned us £9. Is this a sensible way of apportioning public money?
The framework is accelerating the transition to a nurse led primary care system in various ways. It has introduced new hierarchies and helped stratify medical roles.5 Salaried doctors and nurses with special interests are increasingly seen as a more efficient option when medical members of the primary health team need to be replaced. This is helping to open up the primary care market to private providers. The exigencies of the market will drive the numbers of costlier general practice principals down and limit the potential for career advancement for doctors entering general practice. These consequences are not all necessarily negative—nurses have long been the future of primary care—but they are at odds with the public’s desire for “general practitioner led services.”
We know remarkably little about what patients make of these changes. Adherence to single disease based guidelines can override respect for patient autonomy, ignoring the comorbidities that are today’s norm.6 The “McDonaldisation” of general practice—as patients with multiple conditions pass down various clinic-based production lines, leaves little room for the deeper professional relationships patients want.7 Continuity of care isn’t (yet) Qofable.
In historical terms, the framework represents a high water mark in the onward march of what Harrison has termed “scientific bureaucratic medicine.”8 Indicators and guidelines threaten professionalism in various ways. The framework has encouraged external control of clinical practice by “experts” and reduced clinical autonomy. It has provided commissioners with blunt tools for comparing providers and for crude performance management.
Benefits and costs
It is hard to argue against the framework’s benefits to individuals—the reductions in morbidity and mortality. Many of the health gains will be longer term; the benefits of more structured chronic disease management and extensive computerisation may spill over to other areas of practice. The framework has also had positive effects on practice organisation—for example, team working and the diversification of nurse roles.
The question is not whether the framework has had an effect but whether it is cost effective, and here the evidence is sparse. Although indicators in some domains may have been cost effective,9 the opportunity costs are, by any reckoning, considerable. Could the money have been better spent on other public health initiatives? Could these limited improvements have been promoted through other means and other staff?
I am mindful of the myth of a golden age and professional self interest. The development of evidence based medicine, guidelines, and contractual flexibilities all predated the Quality and Outcomes Framework. They were driven by a myriad of policy, regulatory, workforce, and other changes that are changing the face of general practice. However, much can be laid at the framework’s door.
The framework will shrink in time because it won’t deliver what politicians want: savings, public health, quality, or contented users. I look forward to a QOF informed—if not yet QOF-free—future.
Cite this as: BMJ 2010;340:c2710
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares (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) SG sits (unpaid) on the QOF advisory committee at NICE.
Provenance and peer review: Commissioned; not externally peer reviewed.