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Should the QOF focus on outcome targets?

The Quality & Outcomes Framework (QOF) is now well established in primary care. With control of the framework now lying with the National Institute for Health & Clinical Excellence (NICE), we can expect a greater focus on the clinical effectiveness and cost effectiveness of quality indicators. In the early years of the QOF, a large proportion of target payments were awarded for achieving process measures, such as measuring blood pressure or HbA1c. Achievement of such process measures is now very high, with little room for improvement in many practices and limited potential for further health gain.

By contrast, control of key risk factors, such as blood pressure in people with hypertension, or HBA1c in people with diabetes, could still be improved considerably. But changing patients' behaviour or optimising their management to achieve such improvements is difficult and imposes a considerable workload on primary care. So it is logical to consider increasing the financial incentives for achieving better management of such intermediate clinical outcome measures. It is also appropriate to raise the thresholds for achievement of quality targets to ensure practices that provide the very best care are rewarded appropriately for their work.

At the same time as improving the management of patients with established diseases such as diabetes, hypertension and stroke, we also need to reward practices that are effective in preventing disease and delaying the onset of complications once a disease such as diabetes or hypertension is present. The UK is faced with major public health challenges in areas such as obesity, smoking, alcohol and sexual health. Some GPs may argue improvements in such areas are outside the scope of primary care and lie with wider societal interventions. But this underestimates the ingenuity of primary care teams.

There are practices that have implemented innovative schemes in targeting public health, with support from their primary care organisations. An example is the QOF Plus scheme in Hammersmith and Fulham PCT, which has incentivised reductions in smoking and alcohol misuse, and areas such as cardiovascular disease prevention. An example of such an indicator might be the proportion of patients with newly identified impaired fasting glycaemia or impaired glucose tolerance who progress to normoglycaemia after entering a disease prevention programme. Practices that can implement effective interventions to improve management in these areas will have a direct impact on the health of their patients, and should be rewarded.

Outcome-based quality targets, whether for clinical indicators or public health indicators, are more difficult to achieve in some sections of the population. GPs working in inner-city areas may feel they have to work much harder and invest more practice resources to perform well on outcome-based quality targets. This is true - but we can address this by ensuring that, where appropriate, payments for achieving quality targets reflect the population GPs serve, to ensure those working with vulnerable populations are rewarded sufficiently for providing high-quality care and starting to address health inequalities.

We are right to be proud of the NHS. We all want it to provide high-quality care. Despite our best intentions, a considerable gap remains between best achievable practice and the quality of care actually being provided. Focusing the QOF on clinical outcomes will help address this quality gap by rewarding practices that ensure our patients receive the care they need to maintain their health, prevent the onset of disease and optimise their management when patients do develop a chronic disease.

Source: Pulse August 5th 2009

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