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QOF: Losing my religion


19 April 2013

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With the start of the new QOF year and the introduction of a whole host of new indicators, I find myself wondering whether all of this effort is actually doing my patients any good. By chance I came across a paper that was published last summer which has given me more than the usual pause for thought.

With the start of the new QOF year and the introduction of a whole host of new indicators, I find myself wondering whether all of this effort is actually doing my patients any good. By chance I came across a paper that was published last summer which has given me more than the usual pause for thought.

Professor Blackman of the Open University looked at attempts to reduce the teenage pregnancy rate. In particular he studied areas that had previously been identified as having a health need and had been designated as Spearhead areas. These were areas that tended to have a higher rate of teenage pregnancy than the national average. 
Five years later, changes to teenage pregnancy rates were noted and the study attempted to explain the variations between the local authority areas. They used the “pregnancy gap” which was a measure of how much the local pregnancy rate differed from the national average.
After analysis they found that the gap had become larger in several areas. There were three factors associated with a widening gap. First was a high number of drug users, second was lower number of under 18s and third was high quality commissioning.
That was quite a surprise. High quality commissioning was associated with poorer outputs. It was suggested in the paper that these areas were spending more time on the paperwork and meetings than the assessment of quality, meaning they were less effective on the ground.
Now this is a single study and there is no suggestion healthcare can be effective in anarchy. However it is clear that achieving excellence in these assessments is time consuming and they are not necessarily measuring what is useful to patients.
This is what concerns me about QOF. 
It takes up a large amount of time and there is very little evidence that high scoring practices deliver significantly better care than their lower scoring neighbours.
I may be a little behind the times in some of these concerns. The BMA’s General Practitioners Committee has called for a simplified QOF and two members of the NICE QOF advisory committee wrote in last week’s BMJ suggesting that the whole scheme should be reduced in size. A more direct opinion piece in the same issue was entitled “Kill the QOF”. Something in the air suggests we are close to the tipping point. 
None of this happens in isolation. Revalidation, CQC and even some CCG oversight have arrived over the past year bringing yet more paperwork-based assessment of performance. CCGs themselves have just been through authorisation, itself a huge paper-based exercise. 
At almost every stage we have been convinced that what we’re doing is for the benefit of patients but there is now some evidence that may not be the case.
Good systems are clearly necessary for effective health care, but excessive concentration on process may derail outcomes. We are told that assessment pushes up standards. Perhaps it is time that we demanded some evidence for this.
 
Stephen Gillam, Nicholas Steel. The Quality and Outcomes Framework—where next? BMJ 2013; 346 doi: ( 7 February 2013)
Tim Blackman (2013). Exploring Explanations for Local Reductions in Teenage Pregnancy Rates in England: An Approach Using Qualitative Comparative Analysis.
Social Policy and Society, 12, pp 61-72. doi:10.1017/S1474746412000358.
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