The Quality and Outcomes Framework

QOF - Transforming General Practice

Stephen Gillam, Niro Siriwardena

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315357607
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The Quality and Outcomes Framework has deeply divided UK general practitioners. I commend this book and applaud its determination to scrutinise every aspect of the Quality and Outcomes Framework - good and bad and in-between. - From the Foreword by Iona Heath General practice in the UK faces transformation following the introduction of the Quality & Outcomes Framework (QOF), a pay-for-performance scheme unprecedented in the NHS, and the most comprehensive scheme of its kind in the world. Champions claim the QOF advances the quality of primary care; detractors fear the end of general practice as we know it. The introduction of the QOF provides a unique opportunity for research, analysis and reflection. This book is the first comprehensive analysis of the impact of the QOF, examining the claims and counter-claims in depth through the experience of those delivering QOF, comparisons with other countries, and analysis of the wealth of research evidence emerging. Assessments of the true impact of QOF will influence the development of health services in the UK and beyond. This book is essential reading for anyone with an interest in the future of general practice and primary care, including health professionals, trainers, students, MRCGP candidates and researchers, managers, and policy-makers and shapers.

PART I

Background to the Quality and Outcomes Framework

CHAPTER 1

Introduction: development, impact and implications

Steve Gillam and A Niroshan Siriwardena

SUMMARY

The Quality and Outcomes Framework (QOF), introduced into UK general practice in 2004, is unarguably the most comprehensive national primary care pay-for-performance (P4P) scheme in the world. A natural experiment on such a large scale provides extraordinary possibilities for research, analysis and reflection. This book is an attempt to make use of this unique opportunity to explore the scheme in depth.

In this introductory chapter, we describe the contents of each section and how they fit together. Although each chapter stands alone, together they construct a more coherent picture of the QOF. The book considers the origins of the QOF and how it is being developed further; it seeks to summarise and analyse the research undertaken on its impact, including potential unintended or adverse consequences and the gaps in evidence. It provides a viewpoint from practitioners and patients implementing and experiencing the scheme. Finally, it reflects on the lessons for P4P and primary care in the United Kingdom in future and in other settings. In doing so, contributors scrutinise the evidence from the varying perspectives of academic, practitioner, service user and policy analyst.

We hope this book provides practitioners, politicians and policy makers with emerging evidence and critical reflection to inform the development of primary care and P4P systems in the United Kingdom and beyond.

Key points

• Politicians and commissioners of services are seeking mechanisms that will consistently deliver high-quality care.

• The QOF, the most comprehensive national primary care P4P scheme in the world, provides a unique opportunity for research, analysis and reflection.

• This chapter provides an overview of the different sections and chapters of the book and how they construct a coherent picture of the QOF.

• Practitioners, politicians and policy makers should use the emerging evidence and critical reflection on this to inform the development of primary care and P4P systems.

INTRODUCTION

Health services are under ever greater pressure to provide high-quality care that is safe, effective, efficient and timely and where patients’ needs and experiences are heeded.^1,2 The pace of organisational change within the UK National Health Service (NHS) over the last two decades to try and meet these needs has been bewildering. Yet for all that, the rituals and routines of day-to-day general practice have seemed, at least on the surface, to endure without significant alteration. By contrast, the impact of the QOF has, arguably, exceeded that of any other policy development since the Family Doctors’ Charter of 1966. This huge national experiment in performance-related pay has understandably attracted much international attention and is likely to continue to do so.^3,4

The Griffiths reforms of the mid-1980s first introduced private-sector management methods into the NHS.⁵ These methods borrowed on systems theory developed at the Rand corporation that espoused markets, performance indicators, benchmarking, targets and incentives. Alan Enthoven advocated applying these ideas to healthcare; they were reflected in reforms introduced by the conservative government under Margaret Thatcher and the labour administration of Tony Blair that followed.⁶ The QOF has developed within the context of the NHS’ quasi-market that seeks to separate purchasers (‘commissioners’) and providers of care. In historical terms, the QOF represents a high water mark in the onward march of what Harrison has elsewhere termed ‘scientific managerialism’ in healthcare.⁷ The QOF also provides commissioners with albeit crude tools for comparing providers as they seek to break the monopolistic stranglehold of traditional general practice in the UK primary healthcare sector.

Since its introduction in 2004, the effects of the QOF on quality of care have been the subject of pained debate. Six years on, that debate is being informed by an accumulating body of research. As the political and economic environment in the United Kingdom herald further organisational disruption, searching analysis of this evidence is timely. Through an international cast of expert contributors, this book seeks to provide just such a multifaceted review.

STRUCTURE

Part I focuses on the background to the QOF, how it was initially conceived and how it continues to be maintained and developed. Martin Roland describes how the QOF emerged from previous policy initiatives that promoted improvement through clinical audit, within a system of quality and accountability known as clinical governance. He describes how P4P dramatically improved attainments when it was introduced for cervical screening and childhood immunisation, and the influence of a forerunner of the QOF. He provides a fascinating insider’s account of the context for introduction of the framework as well as describing the negotiations and those involved.

Helen Lester and Stephen Campbell further examine the origins of the QOF framework dating back to antecedents that attempted to promote evidence-based primary care. Much development of performance indicators was undertaken in the National Primary Care Research and Development Centre, and they describe how that work progressed. The metamorphosis of what began as a scheme for quality and improvement into a regulated, contractual framework now requires burgeoning technical support for development and implementation of ‘feasible, valid, reliable and piloted “QOFable” clinical indicators’.

Part II summarises, reviews and analyses the research findings: positive, negative and consequences yet unknown or uncertain.

Partly because of its scale and complexity, the impact of the QOF will always be hard to quantify. Nick Steel and Sara Willems, in their broad ranging review of research on the QOF help to identify the impact of the QOF and its effects over and above the preceding secular trends. They explore issues of equity and cost effectiveness arising from the QOF. They also analyse the nature of the evidence, the strengths and flaws inherent in the research and gaps that remain.

A central rationale for the QOF was the need to reduce longstanding variations in the quality of primary care provision. In particular, successive reports had highlighted poor-quality care in more deprived, urban areas.^8,9 Maria Kordowicz and Mark Ashworth explore the notion that the QOF may have increased the quality of chronic disease management or narrowed inequalities in health and healthcare delivery or whether this is an artefact of the system. They discuss whether improvements are more apparent than real – the product of better and more comprehensive data collection. They also discuss the issue of ‘gaming’ and data manipulation.

Focusing their attention on population-wide health improvement and reduction of inequalities, Anna Dixon and Artak Khachatryan examine differences in performance between practices in areas with the worst health and deprivation indicators and those in other areas. They go on to discuss the strength of evidence of narrowing in the equity gap and whether this can be attributed with certainty to the QOF. They argue that the QOF should explicitly address health inequalities in the future development of QOF indicators.

In essence, judgements on the QOF involve balancing sensitive evaluation of the health gains against assessment of its costs, many of which are hard to quantify. Just how hard is apparent from the contribution by Kath Checkland and Steve Harrison. In their analysis of the effects of the QOF on the front line of practice and organisation, they find that greater specialisation among practice nurses has, in turn, promoted extension of the role of other cadres such as healthcare assistants in some practices. They explore how new roles and hierarchies have been created and accepted within practices and how this is affecting morale and motivation.

Part III focuses on practical aspects of the QOF. Chantal Simon and Anna Morton demonstrate how practices can approach the QOF and succeed in achieving high scores through forward planning and good organisation. They also discuss how practices need to make decisions about which targets to pursue as these become progressively harder to achieve and give examples of how practice teams should approach the QOF in a pragmatic way.

Surprisingly, little is known of what service users, the most important stakeholders, think, and several authors comment that there has been little substantive research on the impact of the QOF from the users’ perspective. This point is developed by Patricia Wilkie. In her chapter, she discusses what patients want from their care and focuses on the importance of the relationship between patient and practitioner. She restates the importance of a ‘whole person’ approach and the fragmenting effect of the QOF on continuity and trust. She explores what patients understand by the QOF and the importance of explaining why QOF data are being collected to patients. The QOF has begun another revolution in the assessment of primary healthcare quality through the incorporation of systematic patient feedback. Despite this, many patients probably do not understand the financial framework that general practice operates within and the effect of payments on the actions of the professionals that care for them.

Part IV reflects on P4P within and outside the QOF: its successes, failures and lessons for others. Stephen Peckham and Andrew Wallace show us the broad canvas of international evidence on P4P schemes. It is striking how much the empirical research they amass already relates to the QOF. They argue that although P4P schemes can affect clinical behaviour and processes, its impact on quality more broadly defined (such as patient experience or outcomes) is less clear. Their analysis shows how many of the concerns arising from implementation of this new scheme were predictable on the basis of previous research on P4P.

Finally, Barbara Starfield and Dee Mangin provide an international perspective on P4P and reflect on whether the QOF supports or detracts from those features of primary care systems that underlie their success in promoting health. They question the nature of the QOF’s evidence base and whether such schemes can address comorbidities and the individual variation in patients presenting to general practice.

CONCLUSIONS

Many features of the system within which the QOF operates, such as the internal market, competition and regulation, challenge the philosophies of improvement pioneers of the past. Deming’s five ‘deadly diseases’ – lack of constancy of purpose, emphasising profits and targets, changing management, relying on annual ratings of performance and using visible figures only – are rife in the NHS today.¹⁰ We revisit these ideas in the last chapter to discuss whether the current framework is geared to improve quality of primary care and patient outcomes.

For all those interested in the development of primary care, in the United Kingdom and internationally, these contributions will provide much to reflect upon. The QOF is a natural experiment in progress; verdicts ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• About the editors
• List of contributors
• List of figures
• List of tables
• List of boxes
• Part I: Background to the Quality and Outcomes Framework
• Part II: Impact of the Quality and Outcomes Framework
• Part III: Practical aspects of the Quality and Outcomes Framework
• Part IV: Reflections on pay-for-performance and the Quality and Outcomes Framework
• Index