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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
QOF funds core practice work not just GP pay
- Richard M Vautrey (14 September 2007)
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Is this well informed editorial??
- john sharvill (15 September 2007)
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Vested interests and performance related pay.
- Ian G Quigley (15 September 2007)
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Non-medical viewpoint
- Mark Davies (16 September 2007)
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Payment produces change
- Rupert Gude (17 September 2007)
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suggestions for others' pay
- Owen J Powell (17 September 2007)
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Quality and Outcomes Framework
- David M Shaw (17 September 2007)
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QoF funds golden minutes for risk assessment and prevention
- Mark A Rickenbach (17 September 2007)
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problems with editorial writer selection
- David J Shepherd (18 September 2007)
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Unduly Negative Editorial on Performance Related Pay
- Andrew Wijnberg (18 September 2007)
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Debate
- David Partridge (19 September 2007)
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Measure what matters – The Patient’s Health Experience
- Joachim Sturmberg, Carmel Martin - Canada (21 September 2007)
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Richard M Vautrey, Deputy Chair, General Practitioners Committee BMA House, Tavistock Square, London, WC1H 9JP
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The QOF negotiators are interested in reducing risk and in producing better outcomes for patients. The decision to use certain indicators and not others is based on the evidence that shows they will benefit the patient in front of the GP, not merely because the GP is paid to do so, but because a better outcome will result. Even when the evidence is there, the number of points and the thresholds used are subject to expert scrutiny and the decision by all parties to devote a number of points to the chosen indicator. Professor Guthrie did not present his views to the expert committee on this occasion and so his ideas will not be incorporated into the next round of QOF, should there be any changes in 2008. The current cardiovascular points are awarded for outcomes achieved, not just for recording risk. These have been supported by all the evidence available to date and agreed by experts in the field. Professor Guthrie’s simplified model would devote many points to few activities and would then not support the wide range of processes currently supported by the QOF for the benefit of patients. Dr Wald does not understand that the QOF payments are to reward GPs for their work and to fund the costs of doing so. The money is not just for GP pay but also pays their teams who support them. To remove this funding will damage QOF activity as there will be less resource to support the work that GPs put into reducing cardiac risk. It would also have a significant impact on the core work done within every GP practice which now depends on QOF income to support day to day essential services. None of the treatment tasks in QOF are isolated – they are intended to be part of a coherent whole delivering the best care for patients. The system is already as simple as it can be consistent with delivering high quality care across the disease spectrum. Competing interests: GPC negotiator involved in negotiating changes to the QOF |
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john sharvill, GP Deal Kent
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This article is interesting. There are many aspects of our new contract that must confuse non General Practitioners - as they certainly confuse those of us working with it. One of them is the way primary care is funded . To suggest that qof money is on top of practice income is misleading; it pays for qof related work. One draw back though of this system is a very real danger of EVERY consultation being side tracked by the need to meet qof related data collection in addition to (and potentially instead of) the patients health 'agenda'. Some of the points raised seem woefully out of date such as a suggestion for screening for diabetic retinopathy- standard practice for years. Competing interests: GP who's income in part depends on QOF |
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Ian G Quigley, GP Principle Western Road Medical Centre, 99 Western Rd, RM1 3LS
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The Quality and Outcomes Framework has rewarded GPs for changing the way they think about a number of chronic conditions. When I started as a GP in 1994 a blood pressure of 160/90 was felt by many to be a target to aim for and my colleagues and I would often be unperturbed by readings of up to 170 or 180. Now we spend large amounts of energy and consultation time working to keep people's blood pressure under 140-150. In our diabetic patients we would tolerate an HbA1c of 8.5%. This seems archaic when we now feel a need to take action at a level of 7.6%. The framework has led to a massive increase in the complexity of many of our consultations; one that I think justifies the money being paid. I trust and hope that in 10-20 years time this will be shown to have had a significant impact on vascular disease mortality and morbidity. A cynic might of course realise that it will lead to an increase in people dying slightly older of cancer and dementia. By all means commission analyses of the QOF. Our pay increase needs close and continuing monitoring. However any UK doctor writing it is likely to have a competing interest. Dr Wald, as a cardiologist, stands to lose out in the shift of funds to primary care and he fails to acknowledge this as he criticises the process. I believe we should ask the public what they want from their GPs and then pay GPs to provide it. If they want preventive medicine fine. If they would prefer that money to be spent on immediate 24/7 access to deal with emergency problems then we should be doing that instead. Maybe you need to commission some rather more independent views to influence doctors, their negotiators, the public and the Dept of Health. Competing interests: I am a GP earning money through QOF work |
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Mark Davies, Senior Lecturer in Law University of Sussex
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As a non-medical reader of this editorial I am saddened that the independent professionalism once seen as a hallmark of general practitioners seems to have been overidden by the quest for money. It seems that some of the general public (fuelled by some sections of the news media) are asking what exactly the taxpayer is receiving in return for the extra money pumped into general practice, and whether GPs are being paid extra for doing what a good doctor should have been doing anyway. Justified or not, it seems that the medical profession's communication with the public over this issue leaves a lot to be desired. Competing interests: None declared |
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Rupert Gude, Retired General Practitioner Treveglos, Tavistock, Devon PL19 9EL
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I was surprised to find a hospital based cardiologist writing about problems with performance related pay in primary care. It is not that decisions about primary care should be immune from comment but a lack of the history of the context in which Quality outcome framework (Qof) was introduced together with some factual inaccruacies weakens his assertions. For a long time it has been known that identification of hypertension, initiation of treatment and treatment to target levels has been poor in British General Practice.Despite the independent professionalism of General Practitioners they were either too busy doing other things or just not aware or interested. When Enoch Powell was Minister of Health, he knew that money rather than professionalism was more effective in changing practice. In the late nineties the British Hypertension Society first report led to a concept strange to most nonteaching practices of having a list of hypertensives and a structured system of hypertensive care. This led to targetted care and Qof gave the financial framewok to allow this to happen. As a result of this incentive most practices changed gear and set up systems (including extra staff) to manage hypertension better and thus gain extra payments. The introduction of smoking cessation clinics, free nicotine replacement patches and abolition of tobacco advertising all supplemented this strategy. Huge changes have been made in the way hypertensive patients are managed. Contrary to what is stated no forms have to be filled in and a huge quantity of information on Qof is acquired by distant interogation of our computers. There is remarkable little bureaucracy. More important is that we are given a record of those patients who do not meet various targets and who can be selected for personal intervention. All in all, a brilliant preventive health system. It is strange to read that a cardiologist from an Institute of Peventive Medicine thinks that 'many of the measurements documented are not worth documenting'. Is he referring to whether one smokes, whether one has been encouraged to stop, whether one has had a blood pressure measurement and whether it is still over 150/90? All these are heavily evidence based wortwhile interventions. Professor Wald fundamentally misunderstands General Practice if he thinks that we are just measuring risk factors only. A record needs to exist of blood pressure or smoking status for an intervention to take place. That payments should be made for drugs used flows in the face of the first step in hypertension management which is weight loss, decreased salt and increased exercise which together can be as effective as one hypertensive drug. Qof has revolutionised General Practice. Our patients and their doctors are more aware of the risks they face and it has the potential to be a major factor in disease prevention. It is not perfect and needs fine tuning, changing target levels or percentages as needed. This is in deed where primary care time and resources should go. These are not robotic tasks but basic care that British General Practice failed to implement on a wide scale until the advent of computers and financial incentives. Competing interests: Firm supporter of preventive health care in General Practice |
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Owen J Powell, GP Swansea
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I am extremely disappointed that this was agreed as an editorial for the BMJ, whilst speaking as one of the minority who actually voted against the contract. The argument proposed is circuitous in its logic and misleading in its conclusions. Initially we are told of the extra income available to GPs, with no mention of the extra workload and costs involved in this exercise. Then we move on to the desirability or otherwise of target driven healthcare(with which I agree). Curiously Wald then suggests a different target in the form of percentages of people on therapy( also ignoring the fact that much of current QoF actually includes this). The coup de grace is the idea that QoF payments (GP remuneration for extra workload) should be redirected towards larger prescribing budgets. I would not expect angiography to be funded from a Consultant cardiologist's salary. At a time when General Practice receives negative spin on a daily basis it could do without thinly veiled attacks from its peers published in the BMJ. Most importantly, the editorial completely ignores the patient and his/her autonomy against the incoming tide of polypharmacy. Competing interests: GP |
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David M Shaw, GP Erskine Practice, Arthurstone Medical Centre, Dundee DD4 6QY
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I am writing to express my disappointment with David Wald's editorial. Perhaps it is unreasonable to expect a cardiologist to have particularly accurate knowledge about a general practice payment system designed to pay general practitioners for working with and achieving results on a general practice patient population. However, Dr Wald's article was crippled by basic errors in what the Quality and Outcomes Framework pays for. As well as paying for the outcome measures he rightly wishes to see; it also pays for the framework of registers and monitoring that allow that effective evidence based secondary prevention to be achieved. To suggest hypothecating the "£200 million" he identifies as being superfluous towards "paying for the drugs used", merely adds insult to a basic lack of understanding of our pay structure. Finally Dr Wald will be heartend that his ambition that "Performance indicators should not be based on the measurement of risk factor levels, but on the proportion of people with existing vascular disease or diabetes, or those above a given age who receive effective preventive treatment, in addition to encouraging sensible dietary and lifestyle measures (such as smoking cessation)," is already to a large extent present within the current Quality and Outcomes Framework, should he choose to read it. COI Having had my income frozen for 2 years having "overachieved" makes me slightly tetchy. Competing interests: Practising GP earning money from QoF |
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Mark A Rickenbach, GP Trainer Park Surgery, Hursley Road, Chandlers Ford, Hants SO531LW
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The QoF framework has shifted the focus of primary care from the “Individual problem presented” to the GP at a consultation to an “Individual’s risk factors” which are usually not presented by patients to the GP. Primary care has moved from a responsive to a pro active service with a resultant increase in time pressures and workload. This is something most GPs aspired to in the 1990s but were not resourced to do within the last golden minute of a five to ten minute consultation (1 min prepare/welcome, 1 min listening/summary, 2 min examine, 2 min explain cause/options, 2 min treatments, 1 golden minute for other issues/prevention, 1 min records/goodbye). As Wald says the intervention of QoF has achieved its aim of raising awareness of risk factors. Wald did not point out that the majority of the additional funding for primary care has been used to fund either nurse or doctor time to supplement these golden minutes and address these risk factors. Something that the media seems to have overlooked as well. Any intervention should be tailored to the setting and have follow up in place to be effective (1). Something that Prochaska describes, for patients, as the maintenance stage of an intervention (2). QoF has been effective in establishing and funding a review of risk factors of all the population. We need to ensure the funding for the golden minutes continue. Contrary to Guthrie and also Wald’s statement QoF targets are changing and are already looking at treatments such as uptake of ACE inhibitors in heart disease. This is appropriate but, as Guthrie starts to indicate, a shift of QoF to treatments and outcomes entirely on their own may not allow for the variable of the patient who does not want, or is not suited, or does not respond to the treatments. It may not allow for the uncertainty in medicine and the rapid changes in direction of knowledge about efficacy and side effects of treatments. Any change in incentive targets must be gradual, carefully designed, and allow for all these factors without shedding the achievements so far. To implement effective treatments also requires the professionalism so aptly encouraged by Wald as well as more reliable consistent evidence based data on treatments. The government should focus on interventions in the setting of primary care that enhance professionalism. Perhaps turning attention to increasing the silver minutes of education and review of practice with respect to Guthrie’s “directions” for “treatment intensification” and “stepped care". QoF has established structures to identify and address patient risk factors and ongoing funding is required to sustain this. Let us not denigrate the achievements, or in the process denigrate the GPs who were trying to achieve this. 1) Rickenbach,M.A. Medical Education, professional learning and action research in the Health Service. 2003 PhD Bournemouth University 2) Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G. and et al. Stages of change and decisional balance for 12 problem behaviours. Health Psychol 1994 13, 39-46. Competing interests: Dr Rickenbach is an Associate Dean involved in medical education and a GP whose practice staff have been funded by QoF |
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David J Shepherd, GP Trainer Saffron Group Practice, LE2 6UL
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Why is the BMJ repeating the same mistake as the government in choosing 'blind' secondary care consultants to propose redesigns of primary care, as Iona Heath points out in the same issue? Wald's understanding of the QOF that 'the need to count cases and fill in forms requires extra resources and increases bureaucracy' betrays a profound ignorance of primary care IT & about how the QOF actually functions and so fatally undermines the credibility of the editorial from a primary care perspective. The QOF does not specifically address the issue of primary CVD prevention and so can hardly be criticised for not doing it. His proposed performance indicators do not make sense. Do I get more or less money for having more people with diabetes / CVD on my list? How will we tell whether those above a given age (but we are told specific cut off values are 'inappropriate') have received 'effective preventive treatment'? Presumably we'll measure their BP, cholesterol and smoking status... Competing interests: GP Trainer earning cash from QOF. Patient advocate hearing their concerns about overmedicalisation |
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Andrew Wijnberg, GP Cornhill Surgery, Rubery, Birmingham B45 9JT
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Dr Wald is too downbeat on the QOF for Primary Care. This NHS experiment is a world-first and I think has already lead to driving up standards, particularly in underperforming surgeries. It is worth pointing out clearly to begin with that the QOF payments are not all related to performance "points" as a significant element of the new GMS contract looks at practices' organisational structures. This, in effect, allows the NHS to develop more of a franchise structure, where the global performance of its "independent contractors" is monitored against a national gold standard. Prior to the QOF the NHS had few levers to raise standards within practices. Dr Wald questions the merits of rewarding the maintenance of chronic disease lists, for example, of patients with hypertension. To be sure, diagnosing patients alone will not reduce their risk levels, but this is surely the first step which is required. Furthermore the prevalence statistics for individual practices can then be compared against national and regional yardsticks and any outliers interrogated to find out why they are below or above normal values. Prior to the new GMS contract practices would be paid a majority of their income as capitation fees for just having people on their register, regardless of whether they had been diagnosed or not; now there is a significant proportion of practice income tied in with the identification of risk factors, disease and treatment targets. What is so wrong with using the money lever to achieve this? It is not fair to compare the QOF with paying police to catch criminals or firemen incentives to put out fires; the payments for performance are more akin to a performance pay for the police or fire organisation in achieving national standards in detection rates, prevention and so on. The "de-professionalising" of the primary care performance related pay is a spurious argument; guidelines and evidence-based protocols long predated the QOF and have resulted in the whole medical professional operating more and more rigidly and less on the basis of clinical suspicion and "independent clinical judgement". The space left for clinical "hunches" has become squeezed out by evidence-based protocols, but is this such a bad thing? I am concerned about the one-sided view this editorial promotes which neglects to credit the NHS primary care network for jumping the bar each time it is raised. The QOF has undoubtably raised the bar for a wide range of reasons. Clearly there have been flaws in this new system, but this should not give every expert the opportunity to use it as a target for shooting practice. We in primary care hope for sensible revisions only and a recognition that considerable resources have been employed to get our practices up to QOF standards. Yours sincerely Dr Andrew Wijnberg Competing interests: None declared |
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David Partridge, GP Locum Blackwood farm Rushbury SY6 7EJ
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I would like to hear further comment from those supportive of David Wald (if there are any). An editorial should provoke debate unless for some curious reason it is unsupportable? Competing interests: GP |
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Joachim Sturmberg, A/Prof of General Practice Monash University - Australia, Carmel Martin - Canada
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It is refreshing to see that there are at least some thinkers out there who dare to appeal to us to interpret research finding for what they are worth, and argue for “common sense” responses rather than well-meaning hysteria. (1) Without an agreed framework based on core values, and an understanding of how complex health systems work, it is impossible to synthesize how different research findings 'gel' together and use them to inform policy. Piecemeal interventions that focus only on easily measurable targets without consideration for their impact on the whole individual and the whole system of care are bound to have significant unwanted unintended consequences - for our patients and our professions. Why do we practice medicine? History tells us that medicine evolved over the centuries, because patients experience illness. Illness is distinctively different from disease. (2) As Per Fugelli put it ‘disease does not exist, only the experience of disease [does], (3) with or without feeling ill. If patients consult us for their illnesses, judging the outcome of our efforts in terms of improvement in their health experience (how they experience birth, death, illness and disease etc) would make sense, rather than the simplistic approach of “ticking” rather meaningless process items that ‘bean counters’ can understand. (4) Measuring the patient’s health experience is achievable. As health perceptions and psycho-neuro- immunology research have shown, patient’s health perceptions are a reliable predictor of future morbidity and mortality. (2, 5) And finally while we have to continually juggle certainties and uncertainties in our delivery of health care, and health systems are set up to drive our behaviour towards what brings rewards (a mixture of useful and less useful activities), there is a need to constantly evaluate the resulting changes this has on the provision of necessary care. Professionalism dictates that we provide our patients with ‘wise care’ (the Aristotelian notion of phronesis) – wise care however is not solely determined by NNT (which for most common conditions is high), but also by its reverse, the number treated needlessly (NTN). (6) References 1. Ward D. Problems with performance related pay in primary care. Payments should be based more on treatment and prevention and less on risk factor measurement. British Medical Journal 2007;335:523-524. 2. Sturmberg J. The Foundations of Primary Care. Daring to be Different. Oxford San Francisco: Radcliffe Medical Press, 2007. 3. Fugelli P. Clinical practice: between Aristotle and Cochrane. Schweizer Medizinische Wochenschrift 1998;128:184-188. 4. Rosenberg C. The Tyranny of Diagnosis: Specific Entities and Individual Experience. Milbank Quarterly 2002;80(2):237-260. 5. Kiecolt-Glaser J, McGuire L, Robles T, Glaser R. Psychoneuroimmunology: Psychological Influences on Immune Function and Health. Journal of Consulting and Clinical Psychology 2002;70(3):537-547. 6. Bogaty P, Brophy J. Numbers needed to treat (needlessly?). Lancet 2005;365(9467):1307-1308. Competing interests: None declared |
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