status quo of quo vadis? - KCE

KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 33
2.4.4.3 Evidence for effectiveness
Doran et al. analysed the first year results of the QOF in 8105 practices. They observed
a skew towards very high achievements with a median of 96.7 percent of points (instead
of 75% predicted). This suggests that the targets were easy to achieve but also may
suggest considerable gaming. 68
The costs of the QOF are high: 1.4 billion euros i.e. more than 23 euros per inhabitant.
However, there is some evidence for an effect on the outcomes at the patient level for
chronic diseases. Roland and Campbell recently reviewed the existing evidence on the
QOF. 63, 64 A main finding was that care for some chronic diseases like asthma, diabetes
and coronary heart disease was improving since the introduction of the QOF. The
indicators were already improving before the QOF but the data suggest that care is
now increasing at higher speed. Alternative hypotheses exist, as a better record of the
data since the introduction of the target payment system. Research on pathologies not
covered by the QOF is scarce: that precludes from any conclusion about the impact of
the QOF on other domains of care. Other potential positive and negative consequences
of the QOF were detailed in the paragraph 2.3.6.
2.4.4.4 Future developments
The QOF, introduced in 2004, was updated in 2006. The next update is planned in
2008-2009.
2.4.4.5 Learning points and suggestions for Belgium
The UK GP system early adopted the concepts of quality assessment and improvement.
The first step was the development of guidelines. A major advance was the set up of
payment schemes where GPs received extra remuneration when adhering to preset
quality targets. The introduction of the QOF followed the first experiences of audit in
the nineties. An important financial support helped to establish an IT platform that could
handle all data. GPs were used to collect data and introduced ancillary personnel in
their practices to support all these activities. This culture towards quality and the
necessary structural implications (e.g. IT development) could inspire the Belgian
situation.
Today, about one third of the GPs' income relies on achieving the standards of care.
Studies suggest that targets were easy to achieve but also show that quality of care can
improve by introducing a pay for performance programme.
However, some negative points of the QOF were already described above but the costs
and need for control are also worth mentioning. First, the costs of the QOF are
estimated around 1.4 billion euros just for rewarding the GPs. There is no available data
about the costs for running the whole system. Sceptics argue that the high QOF scores
are explained by the fact that the GPs already reached the targets before the system
started: payments should be surplus rather than a trigger for change. 66 Secondly, a tight
control scheme is necessary to minimise gaming 68 : this may eventually lower the
support among GPs. Additional side effects of using performance indicators were
recently described. They include GPs refusing complex patients, over treatment of
patients who do not benefit from proposed interventions and neglect of the areas not
covered by monitoring. 122 Although the QOF is supposed to cover the entire scope of
general practice, the system is biased towards easily measurable indicators: as an
example, psychiatric care has only a small number of indicators.
Moreover, one may argue that the UK system does not use the full quality cycle and is
not very formative in this respect. This summative system mainly relies on the absence
or presence of indicators.
A final problem is equity: practices in underprivileged areas achieve less points and
hence receive less payment. 66
Another UK initiative that might inspire the Belgian situation is the fellowship of the
Royal College of GPs. A pre-existing condition is a clear and leading status of scientific
professional bodies.