Domhnall MacAuley: Martin Roland in Belfast

Domhnall MacauleyLike it or loathe it, practice will never be the same. Constant data audit, screen reminders, and intrusive disease monitoring protocols have, undoubtedly, altered the consultation but, the Quality and Outcomes Framework (QOF) has, I believe, improved my clinical care. At a recent meeting at the Centre of Excellence for Public Health, Northern Ireland, Martin Roland, one of the main architects of QOF, looked back on how it was developed, what it was designed to do, and how it affected practice, together with some unexpected consequences. It was a unique experiment. 

Like many policy changes, it was an accident of evidence, pragmatism, and money. Pay for performance focused on clinical priorities and stuck to national guidelines with indicators weighted on expected workload. Part of the reasoning was to improve GP income at a time when morale and recruitment were dropping, but government didn’t expect it to be so successful and GP income increased considerably.

Has it improved care? Yes, and it was much more effective than government had anticipated. But, many of the quality markers were already improving, perhaps as a result of interest in EBM, guidelines, audit, and the introduction of appraisal. Plotting the indicators one could already see the trend, but improvement accelerated with pay for performance. Many wondered if targets should be deprivation weighted- but practices in deprived areas did very well without weighting and the gap between affluent and deprived practices narrowed quite rapidly. No other health care intervention has produced such narrowing of inequalities.

There were criticisms. One of most contentious unintended outcome was that, although practices met access targets, it became, paradoxically, more difficult to see one’s doctor as practices responded by changing their appointments systems. And, there were suspicions that GPs might use exception reporting to cheat. Absolutists do not feel there should be exception reporting, but no guideline should apply to every patient so QOF allowed GPs to exclude some patients.

Exception reporting has not been a problem, however, with a remarkably consistent average of 5% exclusions. There was a wide range across practices initially but this has reduced. 

Did money taint the way GPs worked? Money may have been the main incentive, but GPs did not change their behaviour in the way one might have expected if they followed business models based only on reward. They continued to value holistic care and, although improvements may not have been as great in non incentivised areas, they were not neglected. Professional values persisted.

Not all GPs welcomed QOF at the outset but it has not been the threat that some anticipated.  All the data are publicly available for others to see and, perhaps unexpectedly, GPs too have bought into this transparency so that practices often include their QOF scores in advertisements recruiting new partners. 

This experiment worked. Doctors responded and performance indicators have improved. Its success has, perversely, drawn criticism on doctors mainly because of the salary increases. But it remains testament to the achievements of GPs in the UK and their practice teams.

Domhnall Macauley is primary care editor, BMJ