status quo of quo vadis? - KCE

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.