QoF: measuring performance, missing the point

Tags: BMJ GP London QoF Quality

26 Nov 2007

Mechanistic management strategies - embedded into computer software - become fixed and static presenting the danger that innovation will be stifled, according to a critical analysis of the Quality Outcomes Framework (QoF) for measuring GP performance.

The analysis of QoF, published in the BMJ, was completed by an influential team of researchers: GP, Iona Heath; Professor Julia Hippisley-Cox of Nottingham University and Professor Liam Smeeth of the London School of Hygiene and Tropical Medicine.

The thrust of their argument is that targets set through QoF do not necessarily translate into improvements for service users. The problems they see flowing from management strategies embedded in software are part of a raft of queries they raise about the GP performance measurement system.

They write: “Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the QoF, it becomes so.

“Mechanistic blanket management strategies, embedded into computer software, become fixed and static with the danger that innovation will be stifled. Interventions become routine, and practitioners are no longer required to grapple with the innate uncertainty of each different clinical situation.”

“The quality and outcomes framework diminishes the responsibility of doctors to think, to the potential detriment of patients, and encourages a focus on points scored, threshold met, and income generated.

"To give just one example, the failure to make any allowance for age means that doctors are encouraged to overtreat hypertension in old people with the danger of causing fainting, falls, and fractures.”

They identify benefits from QoF but conclude overall that the system is “missing the point.”

“Despite evidence that these sorts of incentives [QoF] improve the quality of documentation while having a much more limited effect on underlying standards of care, there have undoubtedly been useful achievements.

“Of these, probably the most substantial are improvements in diabetic control and innovations in computer prompting systems. However, the system is in danger of missing the point of both quality and general practice.”

The researchers recommend that the QoF should include clinically important outcome measures and should also include mechanisms to measure and monitor potential harms.

Link

Measuring performance and missing the point BMJ 2007;335:1075-1076

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Reader's Comments

Surprise surprise

david.royal@nhs.net

26 Nov 07 12:11

So the penny has finally dropped that the great emperor QAOF really has no clothes. To those of us who completely dispair at the tick-box, mechanistic approach to medicine this comes as no surprise. What on earth was the profession doing in accepting this in the first place. The great mantra "evidence-based" seems to be an all encompassing religion where heretics are ridiculed and reviled and doctors that are sceptical of the evidence deemed to be dangerous and/or underperforming. General practice is about personal care on an individual basis NOT about enforcing population based studies (where only "positive results" are ever published) onto individual patients.

See the debate

Trefor@nhs.net

28 Nov 07 00:11

Please see my reply on the BMJ site.

There has not been time to evaluate the QoF, it is evidence based, what else should we do?

http://www.bmj.com/cgi/eletters/335/7629/1075#180983

QOF used correctly is good for care

tom.heyes@leedspct.nhs.uk

28 Nov 07 09:11

While I have not yet read the original article and I have the utmost respect for its authors I do not agree with the headline conclusions that have been presented. I certainly agree that QOF has the potential to have undesirable effects but correctly understood and in the hands of a skilled GP it does support the application of evidence to individual patient care and correct use of exception coding will allow care to be individualised with little financial penalty. In my former practice it rewarded us for the high standards we were already achieving and provided resources to enable us to drive them still higher. In other practices I have visited, the process of implementing QOF leads to great improvements in care and record keeping, compared to which I see very little evidence of any harm.

Patient safety or income

graham.box@tesco.net

03 Dec 07 10:12

If a GP knows that management of hypertension is dangerous for some older people, and still does it in order to maximise her/his income, what does that tell us about the values of that GP and their commitment (a) to do no harm and (b) to act in the best interests of her/his patients?