Somerset Practice Quality Scheme Evidence Paper
This evidence paper accompanies the SPQS proposal and sets out the evidence and rationale for the proposal. It briefly summarises the development of QOF, the criticisms of QOF and why we think SPQS might deliver better value for patients, clinicians and commissioners.
The development of QOF
It is fair to say that a major focus of improvement strategies in primary care and research into quality in general practice in recent years has been financial incentivisation, both in this country and in others (Dixon and Alakeson, 2010). Although the theory and practice of financial incentivisation has been an element of NHS general practice since the 1950s, it is only since the early 2000s that it has become the major focus of policy and research in relation to general practice. Attempts to measure the quality of general practice became more widespread from the 1980s onwards, spurred by cultural change which sought more accountability from professionals. A number of studies found high levels of apparently unwarranted variation in clinical practice. For example, Seddon et al (2001) undertook a systematic review of quality of clinical care in general practice in the UK, Australia and New Zealand, and concluded that in almost all the studies the quality of care provided did not meet national guidelines or the standards set by the researchers. At the same time, there was a renewed policy focus on access and quality in general practice. This then was the context in which the British Quality and Outcomes Framework (QOF) was introduced in 2004 as a financial incentivisation contract that rewarded practices for adherence to detailed performance of specified clinical processes. The scheme was the most ambitious medical financial incentivisation scheme in the world at the time (Roland, 2004). Criticisms of QOF The two main criticisms of QOF are that it doesn’t work, and that it de-skills GPs. Certainly, the relationship between QOF pay-for-performance and quality is weak; A large-scale study by Campbell et al (2007) was unable to show a difference in improvement trend between clinical indicators which were incentivised and those which were not. A review of the impact of various payment systems in the US on clinical behaviour (Gosden et al, 2006) similarly found that the relationship between payment mechanism and results for patients was unclear. A literature review which included two systematic reviews of pay-for-performance schemes (Peckham and Wallace, 2010) concluded that incentivisation schemes needed to take more account of broader definitions of quality, as it was not clear that incentivised changes to clinical activity translate into improved outcomes and experiences. Another, more recent systematic review (Langdown and Peckham, 2013) confirmed that QOF had had limited effects on health outcome at a population level.
Even Professor Martin Roland, one of the architects of QOF, now believes that the scheme should be scaled back so that performance related pay makes up a smaller proportion of GP income and that only indicators based on clinical consensus should be used (Roland, 2013). While the research evidence is clear that incentivisation does have some effect on clinician behaviour (Doran et al, 2011, there are many pressing issues which are not well-addressed through incentivisation. For example, while QOF has been associated with a general improvement in quality (King’s Fund, 2011), health inequalities have persisted. Alshamsan et al (2010) conducted a systematic review of the impact of pay for performance on health inequalities. The majority of the studies were from the UK and related to QOF. Their conclusion was that inequalities in chronic disease management have largely persisted after the introduction of QOF. These findings have been supported by other major studies (Dixon et al, 2010). Criticisms from the profession often centre on the technocratic quantitative nature of QOF, which appears to undermine the very basis of clinical autonomy. Starfield and Mangin (2010), for example argue that “QOF only addresses a small set of primary care problems, fails to deal with patient’s problems as they experience them, and lacks generalisability to primary care practice”. Howie (2010) explores the complexity of diagnosis in general practice, and concludes that current incentives tend away from what patients and clinicians actually want. For several years following the introduction of QOF in 2004 these criticisms represented a small although influential strain of thought within the profession, but over the last three years those criticisms have become widely shared throughout the profession, and to some extent the policy community. The increased awareness of the medicalisation of care that results from QOF has led to a research focus on unintended consequences (for example, Lester et al, 2011, Chew-Graham et al 2013). There is also a sense in the policy community that QOF is not providing value for money as much of the incentivised activity would be likely to take place anyway. Recent research showing that removal of incentivised indicators has little change on clinical behaviour once those changes are embedded (Kontopantelis et al, 2014) would seem to support this view. If not QOF then what? The research evidence suggests a number of areas that are likely to be fruitful in improving quality in general practice and which do not feature strongly in QOF. These are briefly described below. Measurement acceptable to clinicians Dawda et al (2010) set out some of the challenges to measuring quality in general practice. In particular, they note that the use of benchmarking data which is not controlled for potentially confounding variables such as age, ethnicity and deprivation is of very limited use for inter-practice statistical comparisons. In addition, there are challenges to the introduction to general practice of measures often used in industrial service improvement processes. The development by clinicians of appropriate quality indicators which balance feasibility and validity has been undertaken and described on many occasions (Majeed and Voss, 1995, Marshall et al, 2002, Engels et al, 2005). The absolute requirement for measurements to be designed by clinicians is set out by Ling et al (2012) in their comprehensive evaluation of a major research programme of general practice quality improvement.
Service integration around patient needs Systematic reviews suggest that patients with multiple conditions are poorly served by the NHS, although this appears to a system-wide issue rather than one particularly related to general practice (Goodwin et al, 2010). It is now clear that effective long-term condition management needs to be rooted in primary care but address the whole system of care, including community resources (Coulter et al, 2013). It is also shown in the international literature (Commonwealth Fund 2006) that health systems with a strong primary care focus are more cost effective and deliver better clinical outcomes than other types of health system. The role of GPs in providing what is now called person-centred care has a long conceptual history within general practice, stretching back at least to the 1960s (Balint,1964). It remains an important and valued facet of professional skill today (RCGP, 2013). Urgent care has been an increasing focus of policy concern in recent years as the proportion of the NHS budget spent on urgent care and particularly admissions has continued to increase (National Audit Office, 2013). There are a number of areas where we have fairly good evidence and which are amenable to local action. Bankart et al (2011) demonstrated a relationship between continuity of GP and lower emergency admission rates. Interestingly they also found that there was no relationship between QOF achievement and emergency admission rates. A related study also found a relationship between telephone access and emergency attendances- lower satisfaction with telephone access was associated with higher attendances. There is some evidence that early clinical review by GPs in urgent situations can prevent emergency conveyances and admissions (Fernandes, 2011) and indeed we have some good examples in Somerset, for example the East Mendip Assessment Unit at Frome Community Hospital. Sustainable models of general practice A key concern of the NHS England Call to Action on general practice (NHS England, 2013) is the sustainability of the traditional GP partner provider model. While perspectives and proposed solutions differ, this concern is shared by the Royal College of GPs (RCGP, 2013), the British Medical Association (BMA, 2013) and the policy community (King’s Fund, 2014, Smith et al, 2013). Leaders of the profession have been advocating provider federations for some years but with little success. It is important to note that there is no clear causal link between provider size and quality in general practice, although there are a number of interesting relationships (Campbell, 2001, Ng and Ng, 2013). This has led to some scepticism within the profession about the benefits of federation. However, workforce and funding issues allied to increasing expectations of the role that general practice should play in a modern healthcare system (National Audit Office, 2013) appear to be leading to an increase in larger providers, multiple-contract partnerships, provider networks and mergers, although this is not yet fully evidenced in the literature (Health and Social Care Information Centre, 2014). The major sources are policy papers and the health service and GP press. Some care therefore needs to taken in relation to the source material.
Nonetheless, the experience of health systems that have succeeded in making primary care more sustainable has often been that scale is part of the solution. For example, by introducing a new model of multi-practice provision, the Midlands Health Network in New Zealand appears to have improved the morale of clinicians and services for patients. For example there is now a limit on the number of face to face consultations that GPs undertake each day (Smith et al, 2013). Group Health in the US demonstrated similar gains without an initial focus on multi-practice collaboration, including a 50% reduction in emotional exhaustion in clinical staff (Reid et al, 2010). The consistent theme from the international literature is that whole-system service redesign in general practice is needed, and that small-scale, incoherent improvement initiatives often make things worse. Conclusion The most fruitful areas for a quality scheme that takes us beyond QOF are likely to be improvements in the relationship between general practice and the wider health system, and initiatives that boost morale of practitioners and increase patient satisfaction through greater use of clinical expertise to provide person-centred care. References Alshamsan, R., Majeed, A., Ashworth, M., Car, J., Millett, C. (2010) Impact of pay for performance on inequalities in health care; systematic review, Journal of Health Services Research and Policy, 15 (3) pp178-184 Balint, M. (1964). The doctor, his patient and the illness, London: Pitman Medical. Bankart, M., Baker, R., Rashid, A., Habiba, R., Banerjee,J., Hsu,R., Conroy, S., Agarwal, S., Wilson, A., (2011) Characteristics of general practices associated with emergency admission rates to hospital: a cross-sectional study, Emergency Medicine Journal 2011;28:558-563 doi:10.1136/emj.2010.108548 British Medical Association (2013) Developing General Practice: Providing Healthcare Solutions for the Future, a policy paper, London, BMA Campbell, S., Hann, M., Hacker, J., Burns, C., Oliver, D., Thapar, A., Mead, N., Safran, D., Roland, M. (2001) Identifying predictors of high quality care in English general practice: an observational study, British Medical Journal, 323:784-787 Campbell, S., Reeves, D., Kontopantelis, E., Middleton, E., Sibbald, B., Roland, M. (2007) Quality of primary care in England with the introduction of pay for performance, New England Journal of Medicine, 357, pp181-190 Chew-Graham et al (2013) How QOF is shaping primary care review consultations: a longitudinal qualitative study, BMC Family Practice, 14:103 doi:10.1186/1471-2296-14-103 (published 21 July 2013) Commonwealth Fund. (2006) 2006 International Health Policy Survey of Primary Care Physicians, New York, Commonwealth Fund
Coulter, A., Roberts, S., Dixon, A (2013) Delivering better services for people with long term conditions, London, King’s Fund Dawda, P., Jenkins, R., Varnam, R., (2010), Quality Improvement in General Practice, London, King’s Fund Dixon, J. and Alakeson, V., (2010) Reforming health care: why we need to learn from international experience, London, Nuffield Trust
Dixon, A., Khachatryan, A., Wallace, A., Peckham, S., Boyce, T., Gillam, S. (2010) The Quality and Outcomes Framework: does it reduce health inequalities? Final report. NIHR Service Delivery and Organisation programme. Doran, T., Kontopantelis, E., Valderas, J., Campbell, S., Roland, M., Salisbury, C., Reeves, D. (2011) Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework, British Medical Journal, 10.1136/bmj.d3590 Engels, Y, Campbell, S., Dautzenberg, M., Van den Hombergh, P., Brinkmann, H., Szecsenyi, J., Falcoff, H., Seuntjens, L., Kuenzi, B., Grol, R. (2005) Developing a framework of, and quality indicators for, general practice management in Europe, Family Practice Advanced Access, Originally published 18 February 2005, doi:10.1093/fampra/cmi02 Fernandes, E. (2011) Guidance for commissioning integrated urgent and emergency care, London, Royal College of GPs Centre for Commissioning Gosden. T., Forland, F., Kristiansen, I., Sutton, M., Leese, B., Giuffrida, A., Sergison, M., Pedersen, L. (2006) Captitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians, The Cochrane Library, Goodwin, N., Curry, N., Naylor, C., Ross, S., Duldig, W. (2010) Research paper: managing people with long term conditions, London, King’s Fund Health and Social Care Information Centre (2014) NHS Staff - 2002-2012, General Practice. Available at: http://www.hscic.gov.uk/searchcatalogue?productid=10382&topics=2%2fPrimary+care+services%2fGeneral+practice%2fGeneral+Practice+workforce&sort=Most+recent&size=10&page=1#top (accessed 28/03/14) Howie, J. (2010) Diagnosis in general practice and its implications for quality of care, Journal of Health Services Research and Policy, 15:20 King’s Fund (2011) Improving the quality of care in general practice: Report of an independent enquiry commissioned by The King’s Fund, London, King’s Fund
King’s Fund (2014), Funding and commissioning of general practice; making the case for family care networks, London, King’s Fund Kontopantelis et al (2014) Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework, British Medical Journal, 348:g330 doi: 10.136/bmj.g330 (published 27 January 2014)
Langdown, C., and Peckham, S. (2013) The use of financial incentives to help improve health outcomes: is the quality and outcomes framework fit for purpose? A systematic review, Journal of Public Health, 10.1093/pubmed/ fst077. First published online August 8 2013 Lester, H., Hannon, K., Campbell, S. (2011) Identifying unintended consequences of quality: a qualitative study, British Medical Journal Quality and Safety, 20(12): pp.1057-61 Ling, T., Soper, B., Buxton, M., Hanney, S., Oortwijn, W., Scoggins, A., Steel, N., (2012) Involving primary care clinicians in quality improvement; an independent evaluation of the Health Foundation Engaging with Quality in Primary Care programme, final report, RAND Europe Health Economics Research Group Majeed, F., and Voss, S. (1995) Performance indicators for general practice, British Medical Journal, International Edition, 311.6999 Marshall, M., Campbell, C., Hacker, J., and Roland, M. (Eds) (2002) Quality indicators for general practice: a practical guide for health professionals and managers, London, Royal Society of Medicine Press National Audit Office (2013) Emergency admissions to hospital: managing the demand, London TSO Ng, C., and Ng, K. (2013) Does practice size matter? Review of effects of quality in primary care, British Journal of General Practice, 63(614), pp.604-610 Peckham, S., and Wallace, A. (2010) Pay for performance schemes in primary care: what have we learnt?, Quality in Primary Care, 18, pp.111-116
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Seddon, M., Marshall, M., Campbell, S., Roland, M. (2001) Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand, Quality in Health Care, 10, pp.152-158
