> -----Original Message-----
> From: GP-UK [mailto:[log in to unmask]] On Behalf Of Mary Hawking
> Sent: 20 March 2009 20:26
> To: [log in to unmask]
> Subject: Re: QoF
>
> Saul, I think you are being a bit hard on GPs.

Damn, I was trying to apply masterly objectivity despite "being" one :-)

> When measurable targets are set in any sector, effort will be
> concentrated on meeting them:

Exactly. You therefore have to be *very* sure that the targets/direction set
will actually be beneficial."Guaranteeing" 4 hour waiting times in A&E
sounds like a "good thing" but is accompanied by some perverse behaviour,
suboptimal clinical outcomes, and cost rises that were unanticipated (well
by politicians and health managers)

> >I think there are some undeniable results from QOF
> >
> >1. It is possible to motivate UK GP's to pursue certain
> coding/recall
> >targets with surprisingly small financial carrots
>
> I remember the first year of the New Contract: huge amounts
> of work correcting Coding, extracting and entering data from
> letters and chasing hospitals for information which should
> have been in letters and discharge summaries but wasn't.
> Regardless of finance, my practice manager was determined
> that we would achieve every available point: so we did.
> Good thing we were paperless and had good support from our system.

So you're are agreeing that your practice manager was motivated more by
pride in the practice/personal satisfaction than money, and that lots of
onerous unsatisfying work (mostly administrative) was generated simply to
chase the target.

> >
> >2. Pursuit of the incentivised targets (undeniable?)
> inevitably has an
> >impact on the unincentivised ones (largely because for most GPs the
> >working hours are already filled doing other stuff)

No evidence, n=1 experience that my day is non-stop with no down time,
consequently any more time doing something new = less time doing something
else. Unless you have spare capacity, there's always an opportunity cost.

> I'm not sure about this: do you have any evidence?
> Obviously when you have a pop-up saying "check this" or "item
> missing from QOF" it concentrates your attention.
> As I said, in my practice much of the work in the first year
> was entry of existing data and actively pursing missing data,
> and organising data entry , prompts and nurse-led clinics to
> ensure systematic regular review, including additional nurse training.
> The conditions not included in QOF obviously didn't benefit
> from the systematic approach

...and received less attention, my point 2

> or the tools needed to
> implement this; not sure they actually suffered.

...so you increased time and attention spent on QOF without decreasing time
and attention in other areas? You must be working harder then. Either you
were working at less than 100% effort before and you have just pulled your
socks up, or you are now working at "110%" (is 110% the new accepted minimum
in society? :-) If it's the latter, is the effort sustainable because QOF is
ongoing.

> >3. Despite a promise that all QOF targets would be heavily
> evidenced (snip)
>
> Agree. (snip)
>

Hurrah!

> >4. Increasing achievement scores probably reflect increasing
> >organisational skills at recall/justifying exemption coding
> rather than
> >improved clinical care.
>
> More probably both.

Hmm well if its both, theres a lot more organisation/process improvement
than improved clinical care in improving scores IMO.

Using PHQ9 to diagnose depression, has absolutely not improved my ability to
recognise depression, nor my skills at engaging with and treating patients
with it. In fact I think it inhibits coding depression, wastes time, and is
intrusive in a GP setting. That's not an improvement in clinical care, just
an "improvement" in administration.

> >6. Making the incentive money (which is not the strongest
> motivator of
> >clinicians if you read the research, despite widespread belief) IMO
> >leads to viewing the outcomes in money terms for the
> practice. E.g. if
> >we can get from where we are now to perfect hypertension
> scores that's
> >worth 2000 pounds, but its going to cost us 2500 pounds so its not
> >worth doing
>
> You haven't factored in the time and effort needed as well...
> Agree about the motivation aspect - my practice manager in
> Year 1 9when points weren't worth that much) was more
> motivated by competition with neighbouring practices - or
> maybe thought I would be!

So if money is not the biggest motivator for most healthcare workers, making
the rewards financial largely adds risk. Even the message is wrong. As a
consumer of healthcare I wouldn't even want my doctor to be doing stuff
for/to/with me (even if it's evidence based) because he gets paid more, but
because its good for me, and a satisfying and emotionally rewarding way to
work.

> >
> >7. Difficult to measure targets are under-represented, with
> an emphasis on
> >targets with numbers on
>
> While I would agree with this, if you want/need to apply
> measurements,
> how do you measure things which cannot be measured?
> This doesn't only apply to QOF.

Just because it's not got a number attached, doesn't mean it *can't* be
measured. In fact I would say that's where a lot of the important human
stuff lies. Post bereavement visits/phone calls, making yourself available
to palliative care patients, asking "how are things with you generally?"
rather than closing it down to the presenting complaint, what the college
rather revoltingly refers to as "caritas" might be (I hope) more relevent
things to try to improve than getting the BP under 150/90.

>
> >
> >8. Incentivising one part of the team (the partners) with
> financial reward
> >for (supposed) clinical outcome measures, can cause
> resentment for other
> >team members who do not share the reward (e.g.practice
> nurses, salaried
> >assistants, hospital colleagues) and cause cynicism
>
> This isn't really rational.

Me? or colleagues who might be demotivated? Human behaviour isn't always
overtly rational though.

> If you are an employee in any business, you get paid - and may get
> agreed bonuses depending on agreed performance related pay targets.
> Just because you are working for a small business, should you
> *expect*
> to be paid on the same basis as the owners of the business
> who also take
> the risks if the profits fall?

I never suggested that other team members *should* be paid the same as
equity partners. However, different reward systems might be expected to lead
to different significance to be attached to the target "the reason you are
banging on about recording mental health review done is you're a gready SOB
partner, not because you believe it's a good thing". "why should I work hard
as a DN to do flu jabs for the housebound elderly just so fat cat GP's can
earn more?"

I know the counterarguments, but my point is differential rewards can be
devisive.

> Changes in work patterns are not a reason for profit share: or do you
> think they are/should be?
No

> >Some method to measure long term outcome clinical outcomes (wherever
> >possible not simply the proxy endpoints) is needed. It needs
> to be over the
> >full cycle of care, and the fact that is difficult and
> requires case mix
> >adjustment is no excuse to not do it because 1) there are disturbing
> >variations and (e.g. experience at Bristol) 2) we should all
> want to learn
> >how to do it better.
>
> I agree - but, in the QOF context, as outcomes are likely to be
> long-term and to have involved care in previous organisations
> - and QOF
> is a payment mechanism, don't think this is feasible for QOF.

No it's not QOF, but then my whole thrust is that QOF is a poor way of
improving clinical outcomes, mostly measures process and organisational
skill, shies away from measuring complex stuff, and uses money to motivate
clinicians who are mostly already highly motivated by the idea of delivering
good care (which is a preferable motivation for patients).

>
> >
> >QOF is almost certainly not fitting the bill.
>
> **What is the 'bill'?**
> QOF is about performance related pay.
> Nothing else.

IMO the "performance" it pays for and "rewards" is largely administrative.
If I were in Oz considering implementing a quality system from scratch I
would not go for QOF. From the patient/public perspective I would look more
to a system which encouraged (moving to mandated) clinical outcome
measurement and comparison, and ensured that patient flows were directed
increasingly to the best performers.

Who is the best knee surgeon for a TKR for OA knee in a 75 year old local
(say within 50 miles) to you Mary? How would you know, and what factors
might be considered to be taken into account in assessing excellence. How
does his results (adjusted for casemix OFC) compare to results nationally or
internationally?

Measure the clinical outcomes (especially the long term ones) by condition
(across primary and secondary care), case adjust, make them public and
accessible. Now that would be the basis for a quality improvement program
that I *would* sign up to.


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