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GP targets don’t mean better health

The Quality and Outcomes Framework is too mechanistic

Lisa Hitchen

Friday, 23 November 2007

Targets used by GPs could mean that those worst off are getting worse health care, says doctors and researchers.

In today’s BMJ Dr Iona Heath, a GP in Caversham, London, and colleagues say the Quality and Outcomes Framework (QOF) is all about measuring treatment processes not clinically important outcomes.

Introduced in April 2004, the QOF allows practices to earn points for diseases that three-quarters of the UK population do not have, their analysis points out. This leads to every disease representation group desperate to get their condition inside the QOF so that their patients can benefit.

In the case of depression this has made things worse, they say with: ‘the imposition of standardised questionnaires and scoring systems [that] medicalise distress and unhappiness. Authentic dialogue between doctor and patient is disrupted and many doctors feel fundamentally compromised.’

Both innovation and thinking around the individual needs of patients become reduced through QOF with its: ‘mechanistic blanket management strategies,’ they say. This can lead to harm with a focus on points and income rather than the actual patient. For example with age not being considered in the framework’s hypertension targets, GPs might overtreat older people, leading to faints, falls and fractures.

The QOF was supposed to help reduce health inequalities but it could work the other way. One reason is that those who are poor, with multiple comorbidities, are more likely to be listed as exceptions from its payments. As financial incentives target care away from such patients, they are likely to get lower levels of care.

And doctors will have to work harder to get such people to reach targets as they tend to have worse health. This means that working in areas of social deprivation is less financially desirable to GPs.

What is needed is to translate the increase in process to: ‘tangible outcomes, such as diabetes complication rates or incidence of myocardial infarction,’ Without this the framework’s benefits and cost effectiveness cannot be estimated, they conclude.

But Dr Laurence Buckman, chairman of the BMA’s General Practitioners Committee points out: ‘The QOF is only part of the way GPs care for their patients. General practice includes many aspects of personal care which are not measurable and therefore not part of the QOF. That is why basic funding for practices, the Global Sum, must be sufficient to recognise the needs of all types of patients including those in the most needy areas.’

BMJ 2007; 335: 1075-6

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