Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK
A Niroshan Siriwardena MMedSci PhD FRCGP
Foundation Professor in Primary Care and Editor, Quality in Primary Care, Faculty of Health, Life and Social Sciences, University of Lincoln, Lincoln, UK
Received date: 5 March 2010; Accepted date: 13 March 2010
The pace of organisational change within the National Health Service over the last two decades has been bewildering. Yet for all that, the rituals and routines of day-to-day general practice have seemed to endure without significant alteration. By contrast, the impact of the Quality and Outcomes Framework (QOF) has, arguably, exceeded that of any other policy develop-ment since the Family Doctors’ Charter of 1966. This huge national experiment in performance related pay has understandably attracted much international at-tention and is likely to continue to do so.[1,2]
Since its introduction in 2004, the effects of the QOF on quality of care have been the subject of pained debate. Six years on, that debate is being informed by an accumulating body of research. As the political and economic environment in the UK heralds further organ-isational disruption, searching analysis of this evidence is timely. This themed issue of Quality in Primary Care provides just such a multifaceted and state-of-the-art analysis of the QOF.
Lester and Campbell begin by examining the origins of the QOF framework dating back to precursors that attempted to promote evidence based primary care. Much of the development of performance indicators was undertaken in their own National Primary Care Research and Development Centre. The metamorphosis of what began as a scheme for quality and improve-ment into a regulated, contractual framework now requires burgeoning technical support for develop-ment and implementation of ‘feasible, valid, reliable and piloted ‘‘Qofable’’ clinical indicators’.
Peckham and Wallace show us the broad canvas of international evidence on pay-for-performance (P4P) schemes. It is striking to what extent the empirical research they amass already relates to the QOF. They find that, while P4P schemes can affect clinical behaviour and processes, the impact on more widely defined aspects of quality such as patient experience or out-comes is less clear. Many of the concerns arising from implementation of this new scheme were predictable on the basis of previous research on P4P.
Partly because of its scale and complexity, the impact of the QOF will always be hard to quantify. Thus far, there is weak evidence for what in North America is sometimes called the ‘street lamp effect’: activities outside the glare of financial scrutiny being neglected. Steel and Willems, in their review of research on the QOF, find that care for patients with conditions included in the QOF broadly increased in line with preceding secular trends, while care of conditions out-side the remit of the QOF has neither improved nor deteriorated. They also conclude that there were signifi-cant, albeit small, improvements for some conditions, such as diabetes and asthma, better recording for others, such as epilepsy, and narrowing in some aspects of inequitable care.
A central rationale for the QOF was longstanding variation in the quality of primary care provision. In particular, successive reports had highlighted poor quality care in more deprived, urban areas. Ashworth and Kordowicz also support the notion that QOF has increased the quality of chronic disease management for some conditions and narrowed, if only slightly, inequalities in healthcare delivery. To some extent, these improvements are more apparent than real – the product of better and more comprehensive data collec-tion. Although these authors find little evidence of large scale ‘gaming’, there are indications in other studies of recording bias and data manipulation.
Focusing their attention on population-wide health improvement and reduction of inequalities, Dixon and Khachatryan examine differences in performance between practices in areas with the worst health and deprivation indicators and those in other areas. Their research finds some evidence of narrowing in the gap but this cannot be attributed with certainty to the QOF. They suggest that the limited impact of the QOF reflects the absence of incentives explicitly addressing health inequalities. This should be an area for future development of QOF indicators.
In essence, judgements on the QOF involve balancing sensitive evaluation of the health gains against assess-ment of its costs, many of which are hard to quantify. Just how hard is apparent from the contribution by Checkland and Harrison. In their analysis of the effects of the QOF on the front line of practice and organisation, they illustrate the law of unintended policy consequences: in this instance, the transformation of the primary care workforce and labour market. They find that greater specialisation among practice nurses has in turn promoted extension of the role of other cadres such as healthcare assistants in some practices. New roles and hierarchies have been created and accepted within practices. Practice staff have frequently seen their roles expanded in the past as now but have not always shared the financial benefits. This may explain loss of motivation and demoralisation among staff encountered in other studies.
The transition to a nurse-led primary care system is being accelerated by the QOF in other ways. Since 1997 and the introduction of Personal Medical Services, it has been possible to employ salaried practitioners. Even-tually this opened up the primary care market to private providers. The QOF has accelerated the strati-fication of medical roles. Salaried doctors and nurses with special interests are increasingly being seen as a more ‘cost effcient’ option when senior medical mem-bers of the primary health team need to be replaced. The exigencies of the market may over time drive the numbers of ‘expensive’ GP principals down with the negative consequence of limiting the potential for career advancement for doctors entering general practice.
Doctors are divided in their views on QOF. While acknowledging that the QOF may have improved quality of care and team-working in some areas, many are concerned about the depersonalising impact of the ‘box ticking culture’, the intrusive impact of com-puterised prompts and the move to a more biomedical model of care and away from person-focused care and continuity. This ambivalence is partly explained by the concept of the ‘indeterminacy/technicality ratio’ where ‘technicality’ refers to scientific evidence and rationality whilst ‘indeterminacy’ is synonymous with uncertainty, and individualisation. Some practitioners remain sceptical about the evidence base supporting new indicators. Others feel that the QOF is reducing continuity of care and promoting an overly mechan-istic approach to chronic disease management, in which ‘medicine by numbers’ reduces clinical practice to a series of dichotomised decisions and reinforces a re-ductionist view of quality. The old aphorism, ‘not all that can be measured is important, not all that is important can be measured’, is often cited. Ironically, many important consequences of the QOF might evade measurement.
The Griffths reforms of the mid-1980s first intro-duced private sector management methods into the NHS. In historical terms, from the perspective of policy makers, the QOF represents a high water mark in the onward march of what Harrison has elsewhere termed ‘scientific managerialism’. The QOF provides com-missioners with albeit crude tools for comparing pro-viders as they seek to break the monopolistic stranglehold of traditional general practices in this health sector. But the ‘McDonaldization’ of general practice, as patients with multiple pathologies pass down various clinic-based production lines leaves little room for the deeper professional relationships patients want.
Surprisingly little is known of what service users, the most important stakeholders, think but the QOF has begun another revolution in the assessment of pri-mary health care quality through the incorporation of systematic patient feedback. Despite this, many patients probably do not understand the financial framework that general practice operates within and the effect of payments on the actions of the professionals that care for them.
Finally, as we look to the future, we should not ignore important lessons from the past. In the con-fusion over whether QOF is a quality improvement mechanism or part of a regulatory framework, we should remember that QOF is part of a wider complex system, ‘which is perfectly designed to get the results it achieves.’ Many of the principles underpinning the QOF, the internal market, competition, regulation and many other aspects of the system we are now operating within are a direct challenge to the philos-ophies of improvement pioneers of the past. Deming’s five ‘deadly diseases’; lack of constancy of purpose, emphasising profits and targets, changing manage-ment, relying on annual ratings of performance and using visible figures only, are rife in the NHS. This suggests, from at least one perspective, that the current system is not geared for improvement.
For all those interested in the development of primary care in the UK, these contributions provide much to reflect upon. This themed issue will be ex-panded with a number of other chapters from these and other international experts, including Barbara Starfield, into a forthcoming book entitled The Quality and Outcomes Framework – transforming general practice. The QOF is a natural experiment in progress; verdicts even at this stage of its evolution must be qualified. The QOF and lessons from it are being considered in other countries: for comparing system performance and improving on the indicators used. The potential for its adoption is being examined elsewhere. Policy makers and politicians should be minded to heed the emerging evidence.
Commissioned; not externally Peer Reviewed.