Systematic reviews of something as complicated as the NHS take time and need careful consideration, so are best left to experts, which is why the Policy Research Unit in Commissioning and the Health Care System was commissioned to research the thorny issue of whether the Quality and Outcomes Framework (QOF) was having a positive effect in return for the funds spent on it. The research was carried out by a team at the University of Kent (Lindsay JL Forbes, Catherine Marchand, Tim Doran and Stephen Peckham) and was published this morning in the British Journal of General Practice.
Attempting to improve the lives of those with long-term conditions was a good aim, and there had been a postcode lottery operating before QOF was introduced in 2004. Your chances of receiving best-practice care varied greatly from one GP practice to another before, and QOF certainly seems to have pushed some practices into upgrading their electronic record-keeping and making better use of nursing staff, which has ironed out some inconsistencies that existed before.
“Keeping momentum going can be a difficult objective to achieve, and there is evidence that QOF has not done so.”
Conditions such as type 2 diabetes, serious mental illness and heart disease are complicated, often causing a variety of other problems that all need careful management, so was the QOF performing as hoped to deal with these issues?
Keeping momentum going can be a difficult objective to achieve, and there is evidence that QOF has not done so. Before it was introduced there was low morale amongst GPs, and something clearly needed to be done. There were improvements initially, but there is substantial doubt whether the money that is being spent on this pay-for performance scheme is achieving anything further.
Just simply axing the scheme without replacing the funding, though, would be disastrous, as the authors point out. It forms a substantial part of the budget (10-15%) for most (nearly 99%) of the GP practices in England – Scotland having abolished it in 2016. Having this sort of uncertainty about funding will only make morale amongst GPs, already falling rapidly again back to pre-2004 levels or further, and will do absolutely nothing to improve the care of patients.
Evidence all points to the fact that the NHS needs to do something substantially different in the way it commissions and funds clinical care – and the report authors themselves state ‘In the context of a demoralised primary care workforce, it is important also to consider ways other than financial incentives to motivate primary care teams to deliver high-quality care’.
“GPs have less time and fewer resources to carry out other aspects of health care that might have a greater effect.”
Reading the report, it became increasingly clear to me that things have been skewed by the performance targets sets by QOF – by having to focus on what they are paid to achieve, GPs have less time and fewer resources to carry out other aspects of health care that might have a greater effect. It is a good thing the rate of increase in emergency admissions has been reduced, but there have been no reductions in mortality rates when results of the QOF are compared to those in other countries without pay-for-performance schemes. Short-term gains don’t mean much if long-term outcomes remain the same.
“It’s much more tempting to make a nurse redundant and save on a salary when funds are tight, than it is to switch off a system that’s already bought and paid for.“
Eventually, of course, the QOF will probably be stopped. I hope it will be phased out sensibly and the funding replaced in a way that allows GPs to concentrate on treating patients effectively. The review’s authors don’t believe that stopping the QOF will necessarily have a detrimental effect on patient care, as best practice has already been adopted and is sufficiently bedded-in to be retained.
My own opinion is that, as far as adopting proper data systems goes that’s probably a fair point. I’m less certain about the nurse-led multidisciplinary teams that coordinate care within practices. It’s much more tempting to make a nurse redundant and save on a salary when funds are tight, than it is to switch off a system that’s already bought and paid for.
Year on year under the conservatives I have seen the NHS nibbled away at, under-cut, and its staff denigrated, and this really needs to stop. It is still, just about, a world-class service, and it benefits us all to have it properly run and adequately funded. If you want it in purely economic terms, it benefits the country to have a workforce that is healthy. There have been many scapegoats put forward as reasons why the NHS cannot afford to be funded by taxation alone, and yet it is still far cheaper to run than the American system, so I’m just not buying that argument.
“Under the conservatives, the NHS it is under threat.”
However you look at it, the NHS does a fantastic job overall and is worth keeping. I’m not saying that there aren’t some things that shouldn’t be improved, some people working in it who shouldn’t be, but there are far more success stories than rogue employees. Let’s not throw the baby out with the bath water.
Under the Conservatives, though, it is under threat. Ask anyone who uses front-line services on a regular basis and you will see that ward closures, reduced staffing levels, and services cut to the bone. Satisfaction levels are dropping, unsurprisingly, and the government points the finger of blame at those on the front line, making out that they are troublemakers, greedy, feckless and unable to manage budgets, all while giving less with one hand and taking more away with the other.
Not to put too fine a point on it, the NHS is creaking at the seams, and that is not because it is overfunded and reckless with spending. That’s why this review, although welcome as a tool to help the NHS manage scarce resources wisely, should be treated with respect. Take the authors seriously when they talk about funding stability – do not make it an excuse to pull the rug out from under GPs who are already struggling.
There are many things that need to be done to put the NHS back on its feet, and I am no expert on everything that needs to be done, but there are some things that are obvious. Improving morale would be a good first step, making the NHS feel valued by listening to what staff are saying. That could be done now, and at no cost whatsoever, by simply changing the rhetoric surrounding health care and making it clear that it is no longer under threat from government schemes that might look good on the surface, but which end up costing a lot of money to no purpose.
