Striving for excellence and valuing general practice

The Quality and Outcomes Framework (QOF) has had many proponents and detractors since its introduction over a decade ago, and there’s a great deal we can learn from our experience of it.

The QOF was the first national system of recording and analysing primary care data to publicly compare general practice performance, using a wide mix of structural, process and intermediate outcome measures, with indicators developed for a range of clinical conditions, targets to hit and payments for achieving these.[1] National Institute for Health and Care Excellence’s (NICE) role in developing and validating QOF measures ensures rigorous processes and adds credibility.[2]

However, I believe the Framework is inadequately designed to improve care.[3] Bobby Kennedy’s comment on another indicator (Gross National Product), ‘it measures everything except that which is worthwhile',[4] might not be entirely true of the QOF, but does it capture the essence of general practice?

The Framework employs financial rewards to achieve multiple single indicator targets for individual diseases. The focus on individual diseases does not account for multimorbidity and patients with multiple (and sometimes related) diseases or risk factors, and may be assessed repeatedly and unnecessarily, unless practice systems are designed to take this into account.[2,5]

The disease based approach, emphasising vertical (disease orientated, siloed) rather than horizontal (patient orientated, holistic) integration, risks diminishing patients’ experience of care and narrows both investment and effort.[6] QOF targets have been criticised for being set too low, potentially excluding patients who are more difficult to manage by ignoring them or reporting these as exceptions. And lastly, payments may have diverted broader improvement efforts and had an insidious effect on clinical morale, raised suspicions in our patients and reduced their trust in doctors.

So, what needs to change? We need to decide more than which indicators to use, but also how we use them, redesigning the QOF towards an improvement system. Using funnel plots to benchmark practices and annotated control charts to show improvement over time and the reasons for them, and sharing good practice could better support improvement, already achieved in other sectors.[7]

For indicators to trigger appropriate action we need fewer of them. Having an extensive list of measures may provide a more comprehensive picture but it leaves little time to think about or enact improvement. This enables greater focus on doing more with a smaller number.

For there to be fewer indicators, which should we develop and which should we drop?

Good arguments have been made that we should concentrate on outcome (including patient reported outcome and experience) measures.[5] There should still be room for some key intermediate (proxy), structural and process indicators where evidence links these to positive outcomes. Measuring care bundles, or sets of indicators where each is delivered for every eligible patient (unless there is a valid exception) can reduce the overall number of indicators while measuring care broadly.[7]

Indicators addressing transitions between health and social care are needed to foster organisational co-operation and improve systems of care.[5] For example, the indicator, ‘unplanned hospitalisation for chronic ambulatory care sensitive conditions’ included in the NHS outcomes framework [8] involves pathways from prehospital out-of-hours, ambulance and urgent care services to general practice and community services, with essential support from social services for older people living alone or with disabilities or other care needs.

We should drop indicators for which there is limited evidence, as well as those, which following careful examination, are found to have unintended negative consequences. Indicators which are already performing at a high level and where systems are attuned to maintaining these could be discontinued or only measured periodically to check that quality is being maintained.[9]

Finally, funding would be better spent supporting practices’ efforts to improve care, rather than simply hitting targets. Bobby Kennedy’s words still resonate for general practice today: ‘There is another greater task, it is to confront the poverty of satisfaction - purpose and dignity - that afflicts us all. Too much and for too long, we seemed to have surrendered personal excellence and community values in the mere accumulation of material things.’[4]

A. Niroshan Siriwardena is Professor of Primary and Prehospital Health Care at University of Lincoln

References

        1.    Gillam SJ, Siriwardena AN, Steel N: Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review. Ann Fam Med 2012, 10: 461-468.

        2.    Gillam S, Steel N: The Quality and Outcomes Framework--where next? BMJ 2013, 346: f659.

        3.    Siriwardena AN: Research on the UK Quality and Outcomes Framework (QOF) and answering wider questions on the effectiveness of pay-for-performance (P4P) in health care. Qual Prim Care 2012, 20: 81-82.

        4.    Kennedy RF. Remarks at the University of Kansas, March 18, 1968. Robert F.Kennedy Speeches . 1968.  John F.Kennedy Presidential Library and Museum. 8-9-2015.

        5.    McShane M, Mitchell E: Person centred coordinated care: where does the QOF point us? BMJ 2015, 350: h2540.

        6.    De Maeseneer  J, van Weel C, Egilman D, Mfenyana K, Kaufman A, Sewankambo N: Strengthening primary care: addressing the disparity between vertical and horizontal investment. Br J Gen Pract 2008, 58: 3-4.

        7.    Siriwardena AN, Shaw D, Essam N, Togher FJ, Davy Z, Spaight A et al.: The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England. Implement Sci 2014, 9: 17.

        8.    NHS Group DoH. NHS Outcomes Framework 2015/16.  2014. London, NHS Outcomes Framework, NHS Group, Department of Health. 10-9-2015.

        9.    Siriwardena AN: The ethics of pay-for-performance. Qual Prim Care 2014, 22: 53-55.