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

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)

3. Despite a promise that all QOF targets would be heavily evidenced, they
have become increasingly politicised (it is too tempting for politicians not
to seek to "manage" GPs, and given that we are on public contracts that is
to some extent reasonable)

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

5. QOF is now used as a zero-sum game when it comes to overall GP payment,
much like any "over-perfomance" on the contract resulted in "claw-back".

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

7. Difficult to measure targets are under-represented, with an emphasis on
targets with numbers on

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

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.

QOF is almost certainly not fitting the bill.

-----Original Message-----
From: GP-UK [mailto:[log in to unmask]] On Behalf Of Graham Balin
Sent: 20 March 2009 08:09
To: [log in to unmask]
Subject: QoF

Discussion rages in Aus about how far to copy the UK. Many pundits
stating categorically that the QoF has been shown to be a failure. [with
no references]

Is there any 'evidence' out there? Yeah, sure there will always be docs
who play the system to patient's detriment, but has there been any sign
of an overall improvement in standards of care? If no, is that because
there is evidence of no improvement, or just lack of robust data?

I ask because I abhor tick-box medicine too. As a GP with an > 90%
immunisation rate pre-1990 Contract, I was dead against the introduction
of cut-off points for payment as I felt that a GP in an inner city area
who might be hard pushed to make the lower 70% grade, would in fact give
up trying, and rates would actually decrease. I was proved to be 100%
wrong in this, much as it pains me to admit that bastard K CLarke was
right..

Now I am hearing similar gut-feeling reactions to 'quality markers'-
just it would be fascinating to know the truth about what has happened
since the latest New Contract [and surely some data must be available
somewhere?]

--

Cheerio,

Graham

PS note the rising inflection at the end of the last sentence - I must be
picking up the Aussie accent!



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