We must now scrap exception reporting by GPs in the quality and outcomes framework.

Royal College of GPs chair Clare Gerada was right to say that family doctors will come under the microscope as never before, when they assume responsibility for commissioning. Decisions about rationing are never popular and many of the productivity gains the NHS requires must come from reducing primary care variations, such as prescribing.

It was therefore good to see Liberating the NHS: legislative framework and next steps give explicit recognition to the role commissioning consortia need to play in improving the performance of primary care.

Of course, the government is assuming GP behaviour is more likely to be influenced by fellow GPs than by managers in primary care trusts. That theory is starting to be tested, as pathfinder consortia begin to look into their peers’ performance.

Privately, some do not like what they are finding. As an experiment, I have looked at variation in eight PCT areas: Manchester, Cumbria, Bristol, Dorset, Ealing, Dudley, Hounslow and Portsmouth, all of which are reported to be ahead of schedule in preparing for consortium commissioning. How big are the primary care variations here and what significance do they have for population health?

First, take prescribing variation. Three inhalers for respiratory conditions are among the five most expensive drugs for the NHS. Excessive prescribing of reliever inhalers - which control “lung attacks” but do not prevent them - can also indicate suboptimal care, because oral steroid treatments are needed to control respiratory diseases.

Looking at prescribing patterns for salbutamol, the most prominent reliever inhaler, both Manchester and Cumbria appear to have high prescribing rates while Ealing scores low. The difference between best and worst is 15 percentage points, a substantial margin. This reflects different clinical decisions and different costs to the system, which if standardised could produce better care for less.

Exceptions to the rule

Now let’s look at exception reporting, which allows practices to exclude certain patients from their quality and outcomes framework assessments, in theory to remove any disincentive for practices to take on disadvantaged patients such as residents of care homes. HSJ has previously reported concerns that exception reporting can allow practices to exclude patients in order to maximise income.

Several GPs I spoke to were mortified that neighbouring practices were scoring as highly as theirs, and being paid the same rate, despite excepting hundreds more of their patients.

Nationally, just over 5 per cent of patients in 2009-10 were excluded from the QOF assessment after failing to get an asthma review. But this masks considerable variation. On this measure, once again Manchester and Cumbria score high. In 2009, Manchester had 15 practices which excluded more than 10 per cent of their asthma patients after they failed to get an asthma review; Cumbria had 22 and Bristol 17. Four practices in Manchester and five in Cumbria excluded more than a quarter of their asthma patients. This matters because an annual “MOT” is at the heart of most care pathways for the management of chronic conditions. In places, the figures are heading in the wrong direction. Cumbria saw five extra practices breach the 10 per cent exception reporting rate in 2009 and the figures also deteriorated in Bristol.

Contrast this with the best performers: not one practice in Dudley and just one in Ealing exempted more than 10 per cent of their asthma patients, despite significant levels of disadvantage.

What is the effect on patient care? Unplanned asthma admissions have many causes, including suboptimal primary care, and it would be facile to suggest a direct causal link. It is interesting to note, however, that Dudley PCT, which scored well in my snap survey, has lower than average emergency admissions for asthma, whereas Manchester and Bristol PCTs, which did less well, have significantly higher than average unplanned admissions.

This suggests that health economies that work to improve the effectiveness of primary care in managing long term conditions can achieve benefits in lower emergency admissions. This is true even in disadvantaged urban and rural areas.

When I asked Manchester PCT about its results, it said outlier practices had proven they had attempted to contact patients by letter and verbally before exception reporting. A very high number of patients, they note, either refuse or do not turn up.

NHS Cumbria agreed and said it regularly looks out for practices which demonstrate particularly high exception reporting and work with them to see if they can introduce other methods to engage patients who do not attend medical check-ups.

That is a genuine challenge for it suggests the trouble with exception reporting is not the quality of scrutiny it receives but the fact that it happens in the first place. Rather than rewarding health outcomes, key aspects of QOF are still allowing practices to reap the same rewards, whatever the outcome they achieve. Exception reporting is a barrier to GPs focusing on population health and in the new look NHS surely the time has come for its abolition. l