Published: 26/05/2005, Volume II5, No. 5957 Page 16 17

The quality and outcomes framework was designed to improve patient care by incentivising GPs. But with PCTs facing a large bill, what has been achieved - and was the bar set too low in the first place? Daloni Carlisle reports

Enter into the world of quality and general practice and you open the door to a bewildering set of acronyms and the sound of backslapping as everyone congratulates each other on their massive achievements. But if you scratch the surface a little all is not as rosy as it seems.

The quality and outcomes framework (QOF) is now a year old.

A global first, it came in with the new general medical services contract in April 2004 as a way of rewarding doctors for improving the quality of their services.

Negotiated by the British Medical Association and the NHS Confederation, it envisaged general practice working towards national standards. Some were clinical and based on the best available evidence; others were to do with service organisation. One - access times - while undoubtedly patient-centred also had a political flavour.

GPs would earn around 15-20 per cent of their income through the QOF, winning points for achieving standards. And points mean cash prizes. With 1,050 points up for grabs and an average reward per point of£75 in 2004-05, rising to£120 in 2005-06, plus£9,000 a year for three years to help set up the IT systems to record the data, big bucks were at stake.

In the words of the NHS Confederation's introductory fact sheet: 'This will be the first time any health system will systematically resource GPs on the basis of how well they care for patients rather than simply the number of patients they treat.' Dr Laurence Buckman, deputy chair of the BMA's GPs committee and one of the architects of the QOF, is in no doubt that it has improved patient care. 'The QOF has said to GPs 'If you practice evidence based medicine you will get more money for proof that you have done it and for improved outcomes.' That has to be a good thing. I am proud of it.' NHS Alliance chief executive Mike Sobanja agrees. 'As a result of the QOF general practice has moved in the last 12 months, ' he says. 'The quality of patient care has improved and GPs have exceeded most people's expectations.' And that is where the clouds start to gather. The Department of Health funded the QOF in the expectation that general practices would average 74 per cent achievement - 750 points. In fact, they have gone way beyond that, but primary care trusts have not been funded for the excess.

The full results have yet to be released (and will not be until August 2005) but, says Mr Sobanja, the best 'guesstimates' suggest practices are averaging 900-950 points.

This is proving expensive. 'In the middle of last year our evidence was that practices were set to exceed the expectation by 100 points, creating a shortfall per PCT of£300,000 to£500,000, ' says Mr Sobanja. That has since been overtaken.

One PCT, which wished to remain nameless, said most of its practices were achieving over 1,000 points, leaving it with a£700,000 deficit.

This would be met by increasing the PCT's overspend.

Another non-executive director in a PCT where practices are averaging around 850 points said: 'Frankly It is left us up the creek without a paddle.

Next year is going to be worse as the amount paid per point goes up.' Adrian Jacobs, director of primary care at Torbay PCT, which currently averages 1,000 QOF points, does not have much sympathy.

'If you look at the history of general practice and its ability to respond to financial incentives then it was entirely predictable that GPs would respond well, ' he says. 'Here we made a pretty accurate prediction about what our practices would achieve and made financial provision to cover it.' Torbay PCT was in a minority, it seems. The evidence available so far is that PCTs are in trouble as they face higher than expected bills. In a written answer on February 22 2005, former health minister John Hutton revealed that the biggest single item of planned expenditure for the NHS Bank in 2004-05 was - You have guessed it - QOF achievement. It accounted for£283m of the£746m total.

But that is not the end of the cost to PCTs. Part of the QOF process was a visit to each and every practice to verify their achievements. One PCT source said: 'We spent£25,000 on the review process. That included 33 days of GP time paid at the same rate as GP appraisals, expenses, small payments for our lay assessors, and some management support to the PCT team to make it happen.

Multiply that as an average by 350 PCTs [this is a UK-wide process] and the process itself has cost big bucks.' For the record, if other commissioners spent the same as this PCT, that amounts to a UK-wide figure of close to£9m.

It has been a huge effort, adds Mr Sobanja. A typical PCT would have carried out 50 day-long visits over the three-month review period from October to December 2004.

'It has been a very significant burden on PCTs, but one that has allowed them to develop their relationships with practices, ' he says.

'By and large It is not been an adversarial process - and that was one of the worries.' The high level of achievement must beg the question of whether the QOF is tough enough. NHS Confederation chief executive Dr Gill Morgan was unequivocal in her evidence to the Common select committee on education and skills in March this year, telling MPs: 'We do not think it is good or strong enough.' Many would agree with her, including the BMA, NHS Employers and the NHS Alliance.

Some would go further and say it is fundamentally flawed. A series of short pieces in the British Journal of General Practice published in May revealed deep disquiet.

Here the great and the good of general practice said the QOF was an exercise in box-ticking that was skewing clinical priorities as GPs focus on the point-winning patients.

It comes dangerously close to medicine by numbers, wrote one correspondent.

One academic, who asked to remain nameless, told HSJ: 'Most of the GPs I know say It is money for old rope. It is skewing clinical priorities towards the less unwell and resources towards the wellorganised practices. It is doing nothing to address health inequalities and support struggling practices in some of the worst areas.' A review is currently underway.

An expert panel of academics is gathering the scientific evidence that underpins the standards and is open to submissions until May 30.

This will feed into the overall review that will make recommendations to ministers later this year for a revamp in 2006.

Dr Jacobs, who chairs the process for NHS Employers, says: 'It needs a change. There are elements that we need to look at critically.' Along with Dr Buckman, his co-chair from the BMA, he does not talk specifics.

Mr Sobanja is less coy. 'People say it is too easy but I think that underestimates general practice, ' he says. 'It does have to move on. We have to see more focus on outcome than process and find ways of offering incentives for the conditions not in QOF. And I do not think anyone knows the answer about how to do that.' .


Did the QOF improve quality and offer value? A primary care trust manager recalls. . .

Has it improved patient care?

Possibly. It has tightened up on the recording of some data - blood pressures, and cholesterol - and may have resulted in patients being prescribed appropriate drugs. But in my patch QOF did not change prescribing patterns significantly.

Did it improve patient care by£2.5m worth of value?

Not really. It was partly intended as GPs' pay rise, and some did invest to achieve - on average about£12,000 in my PCT. They made a good return on their money.

Did it measure quality?

When we looked at the nonexistent league tables, there were some surprises [QOF is not intended to produce league tables, but practices can compare their scores with others within their PCT]. The ones we would have rated at the top are not necessarily there. The top achievers were the ones who systematically set out to achieve QOF points.

What was the process like?

We encouraged practices to achieve the best they could rather than taking every opportunity to beat them down. This earned our team co-operation and respect from GPs - essential if we want them to play ball with the wider agenda.

The Department of Health advice on confidentiality was a fiasco, making it legally impossible for PCTs to review QOF achievement properly [because of difficulties in obscuring patients' names].

We did a lot of work on the validity of registers as a good portion of income is based on knowing which of your patients has what condition. Even our very good practices had the occasional patient inappropriately registered.

The less good were inflated on some registers by 20 or even 40 per cent.

The non-clinical domains Many of these were famously described as 'low hanging fruit' - for example, practices gained points for having downloaded copies of policies. But with no guidance on quality or implementation, they were an assessor's nightmare. Can you really fail a practice for the healthcare assistant not knowing about the harassment policy?

We went for the lowest common denominator this year, but can we ratchet up the standards in the future?

Where next?

The QOF is a good idea, but we need to raise some of the standards and criteria. Not a complete redesign, just a bit of tweaking. It has to be continually challenging and hard to achieve top marks if it is to retain credibility.

We must not turn it into a performance management tool. It has to be used by PCTs to encourage and develop good quality practice and to help practices achieve.