Saul, I think you are being a bit hard on GPs.
My recollection is that the government wanted to introduce Performance
Related Pay into General Practice - and insisted that new money would go
into this element of practice finance.
When measurable targets are set in any sector, effort will be
concentrated on meeting them: they are, after all, a definition of what
our employers want us (all NHS organisations including Stafford) to
deliver.
>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.
>
>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)
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 - or the tools needed to implement this; not sure
they actually suffered.
>
>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)
Agree. Woolly "thinking" on the part of politicians. As far as
"managing" GPs goes, what has politics to do with management in the
sense of providing suitable, efficient and VFM services? ;-<
>
>4. Increasing achievement scores probably reflect increasing organisational
>skills at recall/justifying exemption coding rather than improved clinical
>care.
More probably both.
>
>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".
It must have come as a severe shock to find you couldn't just recover
the costs of "over performance" by GPs over the next few years any more
under the New Contract - but, with a rapidly shrinking number of GP
principals, the previous system was failing to deliver - and in danger
of terminal meltdown.
As in 1960 (the first new contract since general Practice was
nationalised by the introduction of the NHS), it was the inability of
the existing system to provide the services needed - and the threat of
total meltdown - that force the government - and Treasury - to agree to
changing a system which, from the financial angle, was so satisfactory
for HMG!
>
>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!
>
>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.
>
>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.
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?
Changes in work patterns are not a reason for profit share: or do you
think they are/should be?
(DOI partner in a practice where we had a few years of trying to recruit
partners: good profitable practice - but few applicants and those not
willing to be involved in management)
>
>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.
>
>QOF is almost certainly not fitting the bill.
**What is the 'bill'?**
QOF is about performance related pay.
Nothing else.
>
>-----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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