QoF: measuring performance, missing the point

Mechanistic management strategies - embedded into computer software - become fixed and static presenting the danger that innovation will be stifled, according to a critical analysis of the Quality Outcomes Framework (QoF) for measuring GP performance.

The analysis of QoF, published in the BMJ, was completed by an influential team of researchers: GP, Iona Heath; Professor Julia Hippisley-Cox of Nottingham University and Professor Liam Smeeth of the London School of Hygiene and Tropical Medicine.

The thrust of their argument is that targets set through QoF do not necessarily translate into improvements for service users. The problems they see flowing from management strategies embedded in software are part of a raft of queries they raise about the GP performance measurement system.

They write: “Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the QoF, it becomes so.

“Mechanistic blanket management strategies, embedded into computer software, become fixed and static with the danger that innovation will be stifled. Interventions become routine, and practitioners are no longer required to grapple with the innate uncertainty of each different clinical situation.”

“The quality and outcomes framework diminishes the responsibility of doctors to think, to the potential detriment of patients, and encourages a focus on points scored, threshold met, and income generated.

"To give just one example, the failure to make any allowance for age means that doctors are encouraged to overtreat hypertension in old people with the danger of causing fainting, falls, and fractures.”

They identify benefits from QoF but conclude overall that the system is “missing the point.”

“Despite evidence that these sorts of incentives [QoF] improve the quality of documentation while having a much more limited effect on underlying standards of care, there have undoubtedly been useful achievements.

“Of these, probably the most substantial are improvements in diabetic control and innovations in computer prompting systems. However, the system is in danger of missing the point of both quality and general practice.”

The researchers recommend that the QoF should include clinically important outcome measures and should also include mechanisms to measure and monitor potential harms.

Link 

Measuring performance and missing the point BMJ 2007;335:1075-1076

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