Primary care in an era of hospital bed reduction: what can we infer from QOF and PBC?

Abstract

Key messages

• The Quality and Outcomes Framework (QOF) has been efficiently and effectively incorporated into practice routines. One possible negative effect of this has been a move towards a more biomedical form of practice.

• There has been patchy but real engagement with practice-based commissioning (PBC), with significant moves in some areas towards GPs acting collectively to improve services across the health economy, including engaging in performance management of each others' practice.

• Together, responses to QOF and PBC suggest that GPs may be willing and able to act both individually and collectively to try to mitigate the negative impacts of future spending reductions

Why this matters to me

General practice will be under a great deal of pressure in the next few years. Understanding the impact of past policy changes is essential if we are to ensure that the core values of general practice are maintained.

Introduction

In this paper we take up two of the questions posed by the guest editors: are there any ‘downsides’ to the Quality and Outcomes Framework (QOF)? And can clinical professionals become more engaged with primary care organisations? Our comments are derived from two recent research studies, the first focusing upon the impact of QOF on practices, and the second exploring the impact of practice-based commissioning (PBC). Other authors have looked quantitatively at the effects of QOF on clinical care,^1,2 and there has been some critical comment on the engagement of GPs with PBC.^3,4 We will not revisit this work; rather, we will use the findings from our own research to shed some light on these two questions. In these studies we took a qualitative approach, and used observations as well as interviews to explore in detail the impact of QOF and of PBC in practice. The substantive results of this work have been reported elsewhere,* and in this paper we summarise our findings and explore the wider implications of what we have found. Readers interested in the details of our methods and findings will find these in the references given below. We conclude this piece by linking our findings to another of the editors' questions: how can GPs be incentivised to respond to a probable reduction in acute hospital beds?

Unsought effects of QOF

Increasing biomedicalisation

There is no doubt that QOF, though more expensive than anticipated, has been highly successful in its own terms and less subject to ‘gaming’ than might have been anticipated. But our interview and observational study of two English and two Scottish general practices suggests that there has been a downside in terms of what might be termed the increased biomedicalisation of primary care. The development of general practice as an academic specialty was in part founded upon the role of GPs as being concerned with ‘the patient's total experience of illness’,⁵ a notion subsequently referred to as ‘patient-centred practice’ or ‘holism’ and often presented in opposition to what is now generally called the ‘biomedical model’,⁶ in which the human body is seen as a host for disease, and therapeutic interventions are directed at the disease rather than the individual. Although this holistic philosophy may not always have been reflected in clinical practice,⁷ QOF potentially represents a distinct turn away from it, being (like many other aspects of contemporary evidence-based medicine) founded on the translation of research evidence into rules for incentivised routine application to classes of patients, defined according to their disease category. Our study found that the practices had made changes that would result in patients receiving a more biomedical, less patient-centred form of care.^8,9 In two practices non-attendance for required QOF checks was not accepted as a legitimate expression of dissent; patients who failed to attend in response to a number of letters would be visited at home. GPs acknowledged that their consultations had acquired an additional QOF-related agenda running alongside and potentially unrelated to the patient's agenda. Thus, for example, reminder systems were set up so that when patients attended for unrelated problems, clinicians would be reminded to weigh them, take blood pressures or check urine. Moreover, it was clear that care had become more dependent upon pharmacological treatments, as QOF requires blood pressure, for example, to be controlled within a certain period of time after diagnosis. Non-pharmacological measures may take time to work, and we found an increased tendency to treat early with tablets.

Organisational and other changes

We also found that this tendency to biomedicalisation was underpinned and perpetuated by technical and organisational changes within the practices. All our practices had established an internal ‘QOF team’, responsible for ensuring systems were in place to collect the necessary data, checking audits to ensure targets were being met, and setting up patient call and recall systems. Data recording via templates had become the norm, thereby defining the nature of the work required by acting as ‘prompts’, and discouraging staff from recording uncoded information that is not important for the QOF process, with the consequent possibility for a nuanced clinical encounter being reduced to a series of ‘yes/no’ answers on a template. We also found evidence that for new, less experienced staff, the templates were used as training devices: ‘doing a cardiovascular check’ became ‘filling in the cardiovascular disease template’. The templates therefore not only structured and shaped clinician–patient encounters in the here-and-now, but their use as training devices ensured that the current definition of the nature of the job would be perpetuated into the future. In all our practices, though attempts were made to minimise duplication, patients with more than one chronic disease were subject to multiple recalls. We also found that the increased use of IT altered practice structures and roles in more subtle ways. ‘Writing the templates’, ‘organising the recall systems’ and ‘chasing’ colleagues to ensure that missing QOF-related checks were made when patients next attended became important roles that altered existing power relationships. In one practice, the immediate response to the announcement of new QOF indicators was to ask the IT team to develop an implementation plan; only later was there any discussion of their clinical merits/demerits by the GPs. In this way new indicators were configured as a technical problem requiring an IT solution, rather than as a clinical problem requiring a clinical response by the doctors.

Rhetoric of ‘no change’

In spite of these quite significant changes, all four practices maintained that there had been ‘no real change’ in response to QOF, that ‘we were doing it already’ or that the additional work had easily been ‘fitted in’ alongside their usual work. QOF has evidently been construed by general practices as a technical problem, which has been efficiently solved. Moreover, in spite of this evidence of a move towards a more biomedical approach, all the GPs whom we interviewed claimed that they still were able to practice ‘holistic’ medicine. However, these claims differed from the traditional perspectives on holism alluded to above, being variously based upon: a metaphorical ‘protected space’ within the consultation; the idea that doctors continued to treat ‘complex’ patients whilst nurses dealt with routine QOF-related work; and the ability of doctors to maintain an ‘overview’ of patient care, even if they were not personally involved.

Summary

In summary, QOF embodies a notion of medical care that is essentially biomedical. Our study practices manifested a move towards a more biomedical, less personalised or holistic approach that had led to changes in the way that patients were treated within the practices. However, the doctors in our study seemed unaware of this change, making rhetorical claims to continue to provide holistic and patient-centred care. The results of studies such ours cannot be said to be ‘representative’ in the statistical sense, and are inevitably small in scale because of the time required to collect and analyse detailed observational data. However, it was striking how similar the trajectories of change that we observed in four practices that had little in common either in the way that they were organised or in the ways in which they identified themselves. This suggests that, whilst caution must be employed, our findings are unlikely to apply only to a narrow subset of practices.

Practice-based commissioning as a route to engagement with primary care organisations

Practice-based commissioning provides general medical practices with an indicative budget to commission services for their patients, though most PBC is actually undertaken by organised groups of general practices often termed ‘consortia’ or ‘clusters’. Official guidance is that at least 70% of any savings should be available to practices to invest in improved patient services and that budgets should include: services covered by the NHS ‘payment-by-results’ (PbR) system; prescribing; community services; and mental health services.

Engagement and legitimacy

Our recently-concluded research¹⁰ included interviews with civil servants, close examination of official documentation, a questionnaire survey of primary care trusts (PCTs), and intensive qualitative fieldwork in 14 varied PBC consortia in eight PCTs. Although PBC has been slow to get off the ground in many localities,¹¹ and some studies have reported limited engagement by individual GPs,¹² we found substantial engagement by GPs with PBC across all our research sites, in that both the overall PBC project and the actions taken in its name were generally seen as legitimate. This was helped by: formal ‘sign-up’ arrangements to the consortium; a sense amongst ‘rank and file’ GPs that they were kept fully informed; systems that ensured that GPs were aware of and able to use new services and/or patient pathways as developed; and a financial incentive scheme perceived to reward work appropriately. Factors that seemed to undermine the perceived legitimacy of PBC were concern that national policy might substantially alter or abolish PBC, and excessively tight control by PCTs. Unsurprisingly, the degree of engagement by individual GPs in the day-to-day activities of PBC varied from participation in consortium governance, through communication of PBC decisions and services to colleagues, to practice-level action such as reviewing referrals and utilising new pathways and services resulting from PBC.

Change attributable to PBC

We found many new services set up in the name of PBC, ranging from local, small scale practice-level innovations to much larger schemes. Not all were established solely as the result of PBC, but PBC provided a convenient vehicle for their ongoing development, management, governance and financing. Such developments usually resulted from active co-operation with local providers and there was little apparent appetite for extending the range of providers. All consortia were keen to provide services themselves and some had established or were planning a ‘provider arm’ as a social enterprise or other type of company. Although this generated concern within PCTs about potential conflicts of interest, in many cases the provision of services by GPs seemed successful, utilising existing premises and expertise, and providing services that integrated well with existing services. Moreover, all sites had developed systems aimed at reducing demand for hospital services, including peer review of referrals and audit of specific service areas, though consortia often complained of insufficient support in analysing hospital activity statistics and arrangements for the provision of managerial support to consortia were sometimes unclear. Arrangements for demand management were more likely to be implemented at practice level where GPs accepted the overall legitimacy of PBC. Importantly, we found a new willingness by GPs to engage in peer review and performance management of each others' work, although some preferred to describe this as ‘levelling up’ or ‘education’. Mechanisms observed included: practice visits to discuss performance against budgets; publication of named performance data; open discussion of performance data; and the use of PBC as a mechanism to implement a wider performance assessment framework.

Budgets and savings

We found that financial arrangements were often a source of contention. First, the scope of PBC budgets was usually confined to prescribing and PbR despite the existence of an appetite in consortia for budgets for community or mental health, areas that have a very direct impact on the work of GPs. Second, although many consortia had made savings, there was no overall consensus about how such savings should be calculated, or about whether or not it was meaningful to regard savings as ‘planned’ or ‘unplanned’. The absence of consensus about this led in some sites to uncertainty and contention about the possibilities of reinvestment whilst, unsurprisingly, consortia with formal agreements about how savings were to be calculated and used were less likely to report conflict.

Summary

We found that PBC had made a good deal of progress, albeit with considerable local variation¹³ and sometimes restrained by perceived organisational ‘barriers’.¹⁴ As with our QOF study, we cannot claim that our sample of PCTs and consortia was representative; nevertheless, the findings serve to show what it is possible for PBC to achieve.

Concluding remarks

Readers will have their own view about the desirability or otherwise of increasingly biomedicalised and less holistic primary medical care. Whatever one's position on this, GPs' local implementation of various means to secure QOF points provides a graphic illustration that ‘traditional’ general practices can organise themselves in an extremely efficient and (in the terms of QOF itself) effective manner, albeit in the context of strong and largely direct incentives. Experience with PBC further demonstrates that GPs are also collectively capable of self-organising in order to take a wider perspective on the local healthcare economy than just the provision of traditional general medical services. At least some PBC consortia have been capable of translating such a broader perspective into action, in the form of new services and new patient pathways that may divert patients away from hospital settings, strategies likely to be crucial in an NHS quasi-market whose transaction rules are at present heavily stacked in favour of hospitals.¹⁵ Furthermore, some groups of GPs showed themselves to be willing to engage with the difficult question of performance management within the group, with potentially important implications for the overall quality of patient care. It is particularly interesting that this has been achieved in response to incentives that are for the most part indirect (budgetary savings are for reinvestment) and somewhat uncertain (given the disputes about calculation of savings). As the NHS enters an era of resource constraint, in which it is difficult to see how reductions in hospital beds can be avoided, our evidence about GPs' responses to QOF and PBC should serve to provide some confidence that GPs may be willing and able to contribute to local efforts to address the consequences of such reductions. Finally, it is not self-evident from our study of PBC that the incentives to do so need to be as strong and direct as those associated with QOF. Voluntary engagement, formal sign up and the experience of successful service redesign were all important in establishing the legitimacy and credibility of local PBC consortia. Whilst guaranteed access to any savings made might well have helped the process of establishing legitimacy, it is not clear from our research exactly what the proposed ‘hard budgets’ for PBC¹⁶ would have added to the mix.