Evidence of net benefit is lacking

Earlier this year, while on study leave in the UK, we were asked to write a piece on the quality and outcomes framework (QOF).¹ The more we read and spoke to general practitioners, the more dispirited we became. The mixture of supportive wisdom and self righteous defensive anger in the rapid responses to Heath et al’s article echoes the range of views we heard.² Clearly (to our jaundiced eyes looking down the barrel of a New Zealand QOF in the making) some (often those who had been around a while) had the wisdom and insight to see QOF for what it is—an unfortunate and far reaching ideological experiment based on pay for performance, which has little or no rigorous evidence base. We would argue that it is a simplistic and flawed system, which skews the value of measurability over meaningfulness (ignoring that they are often inversely related); an external, top-down imposed system of bribery that has transformed the workload and capacity of general practice; a system with unquantifiable opportunity costs in time now unavailable to deal with patients’ concerns and an incremental loss of professional identity; a system based on coercion of doctors, and through them patients, and if that doesn’t work, gaming through exception reporting. The result will be a perceived reduction in the need, if not (yet) ability, for individual critical thought, which will inevitably be diminished, to the disadvantage of patients.

Some GPs are doing very nicely out of QOF—so defensive and secure in their justification that they are doing a great job and that clever folk have ensured that the indicators are evidence based and that their patients must be better off.

Thankfully, we also met many thoughtful GPs who, while seeing some gains, are increasingly troubled and unsure of the net benefit of the system to them and their patients. It would be good to hear more from the worried fence sitters in these columns.