Wednesday 14 November 2012

GP quality and outcomes framework indicators focus on the wrong issues

GP quality and outcomes framework indicators focus on the wrong issues: Doctors are finding QOF indicators harder to meet. And these quality targets do not always improve patient care either.

In the last few months the government has been engaged in lengthy discussions with the British Medical Association on how best to introduce further reforms within general practice. The talks between the government and the BMA's general practitioners committee (GPC) have now broken down and we are being told the government wants to impose changes to the 2013-14 GP contract. This is at a time when we are already dealing with significant challenges through GP commissioning and the drive to make efficiency savings, while continuing to offer high levels of patient care.
The key areas of contention are variability in funding between practices, which I have previously written about, and quality and outcomes framework (QOF) indicators. Many small practices rely on QOF payments to balance their books. QOF contains groups of indicators against which practices are scored depending on their level of achievement in improving patient care. Depression, heart disease, stroke, smoking cessation and flu vaccination uptake are some of the many QOF indicators.
QOF indicators become harder to meet each year as thresholds are raised, and the government's latest proposals mean the threshold for payment for many indicators could rise to as high as 95%. These are unrealistic thresholds with little evidence base, and are designed to claw back money rather than improve patient care. Despite our efforts, we all have some patients whose blood pressure or diabetes is hard to control. They need more time with the GP, practice nurse or pharmacist. The new QOF thresholds would, in effect, penalise practices for these patients, especially in areas of high deprivation.
Smaller practices are also likely to lack the resources to employ staff to deal with the considerable increase in QOF-associated workload. An average GP will see 30 to 40 patients a day, write out piles of prescriptions, action blood results and read hospital discharge letters. There is very little extra time to devote to further QOF work.
Laura attends my surgery to discuss her mood, which has recently worsened following a marital break-up. She is anxious and tearful and wants to discuss psychological therapy but is fearful of antidepressants. My IT system alerts me that she needs a blood pressure check and that I must ask her whether she smokes, offer her cessation advice if necessary and record it all for QOF points. But what Laura needs is access to talking therapies (many of which have long waiting times), not QOF targets. Yet we reward GPs for meeting these targets, assuming that those who don't must be failing their patients.
We should concentrate instead on improving patient care through increasing access to GPs and the time spent in consultations. These are the two areas that patients say they value most.
I understand that we all need to make savings and offer value for money. But it does not make sense to impose change, especially at a time of uncertainty and when GPs are taking on commissioning responsibilities. The government promises us an uplift of 1.5% in basic GP pay if we accept the many unacceptable proposals, but is in fact threatening to drastically cut practice incomes through these changes. This is likely to hit the less well-resourced GP practices hardest, and they may find it difficult to retain doctors as a result. I would therefore urge the government to meet us halfway.
The GPC has made its own proposals, including increasing QOF thresholds for some indicators, but not all. This would be a better way to try to improve patient care and provide value for money.
• Zara Aziz is a GP partner in a practice in north-east Bristol. She is part of the local GP consortia group The Guardian

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