“Half of what were are going to teach you will be wrong” – said the head of my medical school as we sat nervously on our first day. He was, of course, correct (I suppose he had a 50:50 chance).
The foundation of knowledge and evidence in medicine is constantly shifting, necessitating frequent rebuilding of structures built on top.
“Half of what were are going to teach you will be wrong” – said the head of my medical school as we sat nervously on our first day. He was, of course, correct (I suppose he had a 50:50 chance).
The foundation of knowledge and evidence in medicine is constantly shifting, necessitating frequent rebuilding of structures built on top.
I have occasionally described the “Curse of QOF”. It seems to happen frequently around the time that a new area is introduced and a research paper or national guideline is published suggesting that the chosen intervention is either ineffective or positively harmful.
Established indicators don’t necessarily fare much better. Recently it has been suggested that smoking cessation advice is counter productive and a Cochrane review says that treating mild hypertension does not seem to have any benefit for patients.
QOF has a huge number of points devoted to hypertension. Almost one in seven of the UK population has received a diagnosis of hypertension – most of it mild. This could be a big issue now but given a few years the QOF does tend to adapt to the evidence base.
A recent British Medical Journal paper (BMJ 2012;345:e5047) delivers a great blow to the QOF and other medical incentive payment schemes. In examining the evidence that these schemes improve health care, it found a distinct absence.
This is not to say that the incentivised interventions, such as good diabetes control, do not have good evidence of improving patient outcomes. It is simply that there is no evidence that the process of providing incentive payments has a result on patient outcomes.
Absence of evidence is not evidence of absence of course. This is not an original piece of research; there is no new data on the cost effectiveness of the QOF. Indeed this is not just about QOF – the authors level the same accusations against incentive schemes in Australia and the USA.
Many of the general conclusions are based on research on incentives in areas outside medicine. In other complex professional areas, incentive payments seem to reduce motivation and reduce productivity. Even if this does not seem directly relevant it certainly poses some questions about what the framework is for.
Helpfully, the authors supply some questions of their own to be asked of any suggested indicator. Is it worthwhile doing it? Would it have happened anyway? Is this going to lead to perverse results?
None of the current schemes can give a “yes” all of these questions. They are not entirely scientific creations but have been weathered and shaped as they have passed through the political process. With the prospect of a new contract on the distant horizon will there be a desire to continue with a financial incentive scheme?
