status quo of quo vadis? - KCE

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16 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 characteristics are the relevance, validity, reliability, sensibility and specificity. Characteristics in connection with their use are also important i.e. a feasible data collection and an easy interpretation by the stakeholders involved. Finally, good (clinical) quality indicators should bear a potential for improvement and be acceptable within the profession. The KCE report on clinical quality indicators proposed steps to develop quality indicators in Belgium: experts would weigh the evidence and their clinical experience. 3 As the evidence evolves, indicators are subject to development. In the UK for example, indicators are yearly reviewed. 54 However, the development of indicators requires caution 59, 56 : the UK experience shows that the agreement on the applicability and validity of indicators is low, even if they are based on scientific evidence. 47,60 Most indicators relate to the technical aspects of care and deal with chronic conditions. The input from patient groups is rare. 2.3.5 Precursors, enablers and incentives for implementing a quality development framework In the UK, GPs have been long working with audits and measurement using standards: the remuneration for quality was a part of their income. 54 This history may explain the relatively easy evolution towards a quality incentive framework for GPs. 61 Apart from history and culture, other influences are powerful in a quality development system e.g., feedbacks from opinion leaders, teamwork, patients’ perspectives, ownership within the profession and continuous learning. 40 Effective organisation of general practitioners, professional and financial incentives were also identified by the review of King et al. 42 Apart from the financial incentives described above, the focus on quality of individual health care providers and a policy at the national level seem key factors for success. 2.3.6 The Quality Outcomes Framework in the UK The Quality Outcomes Framework (QOF) is an outstanding example of programme for improving quality in general practice at a national level. The description of the QOF is the topic of many papers published in peer reviewed journals. This description will be also further detailed in the chapter 2.4.4. (UK system). The QOF has been a major change for promoting quality in general practice in the UK. 54,62 Essentially, the framework offers financial incentives for general practices according to their results based on specific quality indicators. The range of 146 indicators mainly relate to coronary heart disease, hypertension, diabetes, organisation of the practice and patient experience. According to the authors of published papers, the QOF could lead to the following positive and negative consequences. 2.3.6.1 Positive consequences of the QOF The authors found that the introduction of the QOF was associated with the improvement of indicators for specific chronic conditions 63, 64 . This impact is detailed in the description of the UK system (paragraph 2.4.4.3). Other positive changes include the improvement of GP computer systems, the development of the role of nurses in general practice, the multiplication of clinics specialised in specific chronic diseases, the emphasis on the bio-medical orientation of GPs. 54
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 17 2.3.6.2 Negative consequences of the QOF However the same authors underline potential negative consequences 54,65 : a less holistic approach, reduced continuity of care and care fragmentation are risks identified by the GPs themselves. The sets of QOF indicators mainly cover clinical and technical domains. For instance only about 40 points out of 1050 deal with psychological or psychiatric issues. 66 This means that the actual measurement and subsequent development of quality may be biased towards easy-to-measure indicators and as a consequence, the broadness and holistic nature of the construct of general practice may not be fully covered. 62 This urges the QOF scheme to face the need for a more comprehensive approach of care. 64 A threat is the increasing importance of administrative tasks instead of taking care of the patients 65 . The nurses expressed more concern than doctors about this risk for their clinical practice but also appreciated to have the responsibility for working with targets in particular areas like chronic diseases. 67 The GPs also suggested that care could worsen for conditions not included in the incentive system 65 Research on areas of care that are not in the QOF is very scarce: it is therefore impossible to counteract the hypothesis of a worse quality in these areas. GPs show high levels of reporting quality points. The mean achievement among GPs in the UK is now more than 90 percent of available quality points. 68, 62 Since the introduction of this quality system, the budgets considerably increased as the average GP income rose more than expected (23 percent instead of 18 percent). 62 The scheme may not fully respect the equity principle as practices in socially deprived areas achieve less QOF points and hence less remuneration. 66 There is evidence that larger practices, training practices and practices in privileged areas attain higher scores. 66, 69, 70 Salaried GPs have lower QOF scores. 69 There is some evidence that higher quality points do not reflect better adherence to guidelines, indicating the gap between the relatively simple measures of quality in the QOF (relying on the record of a narrow range of computer codes) and the actual standard of care being delivered. 71 2.3.7 Pan European initiatives The literature describes three pan-European initiatives i.e., OECD Health Care Quality Indicators Project. 72 , the European Practice Assessment tool 73 and the Maturity 74, 75 Matrix. 2.3.7.1 The OECD Health Care Quality Indicators Project The aim of the OECD Health Care Quality Indicators Project 72 is to collect international comparable data on health care outcomes and improvements in OECD countries. Difficulties were practical constraints when reviewing possible indicators and the delineation of the scope of general practice and primary health care in the different European countries. Consensus techniques allowed deriving a limited set of clinical and preventive indicators for primary care, including general practice. This project awaits further implementation. 2.3.7.2 The European Practice Assessment tool The European Practice Assessment tool deals with the organisational aspects of the practice. A conceptual framework for the assessment and quality development of organisational aspects of GP was the basis of this European instrument. 73 Using modified Delphi procedures, Engels et al. worked out a set of indicators on the assessment of general practice. 55 A careful selection procedure decided on a set of indicators considered as valid in the European context. Chapter 3 details a field test of this instrument in Belgium.
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