Reading this and other articles concerning the QOF concept and
outcomes, I am not surprised that improvement in quality of care has been
a little disappointing. Quoting McWhinney: "In a complex system, cause and
effect are not usually close to each other in time and space, and since
organic processes are maintained or changed by multiple influences, it is
difficult to predict the consequences of an intervention"[1]. In
hospitals, where events are close together and descontextualised, process
and outcomes may be more easily measured, but in primary care it just
seems not to be the case.
The RCT creates artificiality. GPs work in a complex environment with
no exclusion criteria, no drop outs, no blinding, but rather a face-to-
face reality full of uncertainty.
On the other hand, the current scientific-bureaucratic medicine -
that translates research evidence into 'clinical guidelines' and now links
this to incentives - may have a reductionist effect on GPs' role, despite
a discourse of 'no change' [2]. Experts in economics and sociology have
described the 'crowded out' effect whereby monetary incentive has the
potential to impair self-determination. They also recognise that this is
less likely to occur in more mechanical tasks than in creative ones [3].
If the QOF prompts the 'no change' perception this creates the rhetoric
paradox: where a holistic approach - which needs creativity - can be
mechanised and reduced to agreed targets (as no 'crowded out' effect was
found). How this new profile of GPs' profession can still be included in
McWhinney's statement of what makes GPs different: "Other fields define
themselves in terms of content: diseases, organ systems or technologies.
Clinicians in other fields form relationships with patients, but in
general practice, the relationship is usually prior to content".
80% of what is considered as quality of care in the QOF relates to
clinical and organizational domains leaving around 20% for the patient's
experience domain and depth of quality measurement. Are GPs content
changing from patient- to target-centred medicine? Should GPs be redefined
as focal specialists on agreed targets?
I am a GP from Brazil currently studying medical anthropology at
Durham University in the UK. I would like to understand the new context
that QOF creates in GPs' workplaces in the UK. It seems that the audit
culture and the new managerialism is transforming the profession of
General Practice for the worse; similar trends are now in play in Brazil.
[1] McWhinnney, I. The importance of being different. British Journal
of General Practice, 1996, 46, 433-436.
[2] Checkland, K. Harrison, S. The impact of the quality and outcomes
framework on practice organisation and service delivery: summary of
evidence from two qualitative studies.Quality in Primary Care 2010;18:139-
46
[3] Marshall, M. Harrison, S. It's about more than money: financial
incentives and internal motivation. Qual Saf Care 2005; 14:4-5. doi:
10.1136/qshc.2004.013193
Rapid Response:
Rethoric Paradox
Reading this and other articles concerning the QOF concept and
outcomes, I am not surprised that improvement in quality of care has been
a little disappointing. Quoting McWhinney: "In a complex system, cause and
effect are not usually close to each other in time and space, and since
organic processes are maintained or changed by multiple influences, it is
difficult to predict the consequences of an intervention"[1]. In
hospitals, where events are close together and descontextualised, process
and outcomes may be more easily measured, but in primary care it just
seems not to be the case.
The RCT creates artificiality. GPs work in a complex environment with
no exclusion criteria, no drop outs, no blinding, but rather a face-to-
face reality full of uncertainty.
On the other hand, the current scientific-bureaucratic medicine -
that translates research evidence into 'clinical guidelines' and now links
this to incentives - may have a reductionist effect on GPs' role, despite
a discourse of 'no change' [2]. Experts in economics and sociology have
described the 'crowded out' effect whereby monetary incentive has the
potential to impair self-determination. They also recognise that this is
less likely to occur in more mechanical tasks than in creative ones [3].
If the QOF prompts the 'no change' perception this creates the rhetoric
paradox: where a holistic approach - which needs creativity - can be
mechanised and reduced to agreed targets (as no 'crowded out' effect was
found). How this new profile of GPs' profession can still be included in
McWhinney's statement of what makes GPs different: "Other fields define
themselves in terms of content: diseases, organ systems or technologies.
Clinicians in other fields form relationships with patients, but in
general practice, the relationship is usually prior to content".
80% of what is considered as quality of care in the QOF relates to
clinical and organizational domains leaving around 20% for the patient's
experience domain and depth of quality measurement. Are GPs content
changing from patient- to target-centred medicine? Should GPs be redefined
as focal specialists on agreed targets?
I am a GP from Brazil currently studying medical anthropology at
Durham University in the UK. I would like to understand the new context
that QOF creates in GPs' workplaces in the UK. It seems that the audit
culture and the new managerialism is transforming the profession of
General Practice for the worse; similar trends are now in play in Brazil.
[1] McWhinnney, I. The importance of being different. British Journal
of General Practice, 1996, 46, 433-436.
[2] Checkland, K. Harrison, S. The impact of the quality and outcomes
framework on practice organisation and service delivery: summary of
evidence from two qualitative studies.Quality in Primary Care 2010;18:139-
46
[3] Marshall, M. Harrison, S. It's about more than money: financial
incentives and internal motivation. Qual Saf Care 2005; 14:4-5. doi:
10.1136/qshc.2004.013193
Competing interests: No competing interests