The 2004 UK GP contract contained the Quality and Outcomes Framework (QOF), the boldest pay for performance scheme in healthcare ever attempted anywhere in the world. Eleven years on and its in trouble.
The QOF was seen as offering the promise of a quantum change in performance rather than an incremental one. It was driven by evidence that some aspects of primary care were not being carried out at optimal levels—for example, the adequate control of blood pressure in people with hypertension and the management of diabetes. With one mighty leap, the NHS vaulted into large scale payment for performance without, it seems, paying too much attention to concerns about the undermining of a professional focus on individual beneficence.
Disappointment with the QOF is not new. Many of the changes in clinical practice measured since 2004 have simply been continuations of pre-existing trends; rightly or wrongly, evidence adoption by clinicians and patients usually takes some time. And there have been many unintended consequences, notably the slow, unconscious professional slide into an inappropriate emphasis on following algorithmic rules. I recall vividly the GP recounting his consultation with a man in his 80s recently bereaved; the GP’s focus was on caring for his patient in this important consultation when words, kindness, and silences meant more than actions. Yet the GP’s computer was a significant distraction, telling him to take the patient’s blood pressure for QOF reasons—a requirement that was clinically and ethically inappropriate.
Performance management is a tricky business, especially in the public sector. Arguably, the more complex the services provided, the greater need to grant the organisations providing the services autonomy for delivery, for they know best themselves how to manage the competing demands. However, such organisations must also be accountable, because society must be satisfied that appropriate standards are achieved and that the services are value for money.
A major advantage of performance measurement is that in the right environment the data enable organisations to learn from each other. Performance data can be a powerful communication tool, and it seems unlikely that important large changes such as those seen in primary care prescribing in the UK over the last 20 years would have occurred without data which compared organisational performance.
So it’s the Goldilocks principle again—“not too little performance management, not too much.” Last year the number of QOF targets was scaled back and the Secretary of State said he would “remove the lot of them” if he could. The RCGP now want to see the QOF scrapped too, and in Scotland it looks pretty certain that the GP contract in 2017 will “move on” from the QOF. Already we need to be thinking what replaces it.
I’ve been involved in performance management of prescribing for about 20 years and devising appropriate measures is far from easy. We once asked for suggestions for new or improved prescribing measures. If my memory serves me correctly we received 159 suggestions; 158 of them were not in line with the evidence, were technically impossible to produce because the data did not exist, or were already in routine use. Some years on, introducing a version of the 159th is still being discussed because of the risks of unintended consequences. There should rightly be plenty of head-scratching going on about the son or daughter of QOF.
And then some of the fog clears. Maggie Helliwell—long time Yorkshire colleague, trenchant GP, and vice-chair of NICE—sent me a file describing the pattern of deaths in her Keighley practice over the past 10 years. It came about because of an email group conversation about the management of people with frailty and multimorbidity. The data are, of course, anomymised and unpublished yet it’s a terrific example of how one practice’s experiences can say more about a problem than all the academic reports in the world.
55% of the deaths were over 80 and 22% over 90. Cancer, dementia, old age, and chest infections dominate the causes of death now; over the 10 years the deaths from acute myocardial infarction and stroke have dwindled to almost none. About 60% of deaths were at home or in nursing homes.
What leaps off the page and smacks you around the head is the sheer numbers of older people with multimorbidity; the current single disease, single guideline focused QOF looks pretty much irrelevant to the care of such people and the people trying to deliver that care. Our support for clinicians handling this complexity looks inadequate too—so much education and research is still single disease focused.
The words we use when caring for such patients matter, the teamwork matters, and so does the timeframe. Measuring how we did this year about such things just looks so wrong. Primary care is about sticking it out for the long term—rocking up for work day after day, year after year, looking after people unselfishly, and on their terms whatever the complexity of that decision making. A one year snapshot of often process measures rather than outcomes, and saying “job done” (or not) produces nothing useful. Take a longer perspective with dynamic, locally relevant audit, reflection, and a team commitment to just do better—as the great Julian Tudor Hart did in Glyncorrwg—and what is truly possible emerges.
Is it too much to hope for that this time we could prioritise what matters to patients? In a systematic review of patient priorities for GP care, humaneness ranked as the top priority ahead of competence and technical accuracy. An approach to multimorbidity focused on contraindications and interactions of medicines and lacking better and more conversations about the goals of care looks completely inadequate. There’s no excuse for poor quality technical care of course, but it’s also hard to marshall an argument against a policy that would encourage, appropriately measure, and reward patient-centeredness. In the post-QOF conversations, is that voice being heard?
Neal Maskrey spent 20 years as a GP, the last third combined with developing primary care for a health authority. After 14 years as a director of the National Prescribing Centre and programme director of the Medicines and Prescribing Centre at NICE, he is now honorary professor of evidence informed decision making at Keele University, and co-leads a European evidence based, academic detailing programme at the University of Amsterdam.