Tom Nolan: QOFerendum

The arguments to leave the Quality Outcomes Framework (QOF) have a familiar ring to them: it’s so big it can’t reform; we need to take back control; we should stop wasting money on bureaucracy and fund the NHS instead; what do the so called experts know about real life?

These seem to be working just as well for QOFxit as they did for Brexit.

All the noises from the government and the BMA suggest QOFs days are numbered, although for the time being it remains. But if it ever comes to a QOFerendum, I’ll be voting to remain.

QOF is no Brussels. It isn’t the bureaucratic monster it once was. QOF data is easy to code and track, and there are no end of year submissions—the data is collected by NHS England automatically. QOF has shown it can reform too: in recent years the more clinically dubious indicators have been retired, and those that remain are evidence based and not nearly as intrusive. As for taking back control, any CCG with level 3 commissioning (most, from 1 April) will have QOF under their remit and will be able to tweak it to their local population needs. There has always been a sense that the experts behind QOF don’t understand what real general practice is like—if they did they wouldn’t have made us do Patient Health Questionnaires (PHQ9s) on everyone with depression. But are our ideas for more local schemes any better? The ones in my area aren’t, but you won’t have heard about them. The external scrutiny of QOF by the likes of Pulse, The BMJ, and the King’s Fund is one of its greatest strengths.

A well oiled machine

Today’s QOF is a smooth, well oiled machine that integrates with every primary care software platform. For GPs this means QOF has found its rightful place in our world—the bottom right corner of the screen (for EMIS users, at least). The population searches that we use to track how we’re doing force GPs to take a step back from individual patient needs to deliver more equitable care at a population level. Local schemes, without the support from the major software platforms tend not to integrate as smoothly with our systems, which inevitably leads to more time wasted wading through spreadsheets and notes.

Remain and reform

Many people who voted remain in the EU referendum were nonetheless deeply unhappy with the way the EU do things, and wanted reform. Likewise, wanting to keep QOF doesn’t mean it doesn’t need reforming. We should turn our attention to better scrutiny of how we use QOF as an evidence base checklist for good care. Better auditing of records could be a start, to ensure that we use QOF indicators as prompts to have meaningful discussions with our patients rather than seeing them as sheep to be counted through a pen. A shift in emphasis to encourage shared decision making would be another step forward.

What can we expect in a post QOFxit world? We know that when financial incentives have been removed from quality indicators, performance levels decline. Many practices will no doubt keep the reminders on their clinical system, but spend less time chasing up their hard to reach patients, thereby widening health inequalities. Enough of project fear though. More importantly, at a time when thinkers like Atul Gawande have convinced us that checklists can bring benefits when used intelligently and sensibly, why would we turn our back on ours?

GPs won’t have a referendum on QOF but we may get a say via our CCGs. I’ll be voting to remain and reform. Don’t let the QOxiteers win.

Tom Nolan is a GP partner in South London.

Competing interests: None declared.