status quo of quo vadis? - KCE

40 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76
2.5.1 Steppingstones for a quality framework: a vision based on a national
policy
The existence of a national quality policy is a major condition to succeed in quality
development. The professionals with the support of the Royal College set up the
conceptual framework in Australia. In the UK, the success of the QOF relies on a pre
existing framework for audits that paved the path for the QOF (GPs and their
organisations were accustomed to use indicators).
The scientific bodies of GPs have a strong influence in the successful countries and the
profession has a culture oriented towards quality. The UK and the Netherlands have
responded to the implicit needs of the society and the government adopted a plan for
quality. In Australia, the GP profession developed its own vision within a quality
framework. In Germany the government imposed a system that is now worked out by
various commercial and competing bodies.
2.5.2 The components of a quality framework
Contencin et al. described peer review, audit and practice visits as the major
components of European quality systems. 40 All countries studied in this report have
their own mix of initiatives within their quality system. The UK, the Netherlands,
Australia and Germany have a trend towards practice based quality development.
Usually an independent body is in charge of the data collection. In the example of
Australia and in the Netherlands, GP associations (the Australian network, the Dutch
College) own the data. The accreditation might also be under the responsibility of
independent bodies, as in Germany or Australia, whereas in France the professional
organisations are much more involved.
2.5.3 Purpose of the system: summative and formative use
The debate between summative or formative use of a quality development system is not
finished. The UK QOF scheme puts the emphasis on increasing the income (summative
approach) and neglects the quality cycle, whereas the Australian approach is far more
formative. The GP networks provide regional feedback to practices, giving to the GPs
the tools for improvement. The co-existing practice accreditation and financial
incentives complements the Australian quality system.
The summative use of a quality development system may lead to professional sabotage,
gaming or delegating the quality work to other members of the GP team. In the QOF
(UK) high levels of exemption reporting triggers extra control on the profession. In
Germany, GPs may choose their independent accrediting body and many GPs choose
the easiest solution.
Probably a mix of summative and formative elements offers a way forward. As an
example, the UK summative system now shifts towards more formative approaches as
peer review techniques.
2.5.4 Pro and contras of clinical indicators: the UK experience
In the UK, the QOF greatly changed the landscape of general practice. The quality
debate is now on the validity of the indicators. Some authors argue that they are too
simplistic and do not encompass the comprehensiveness of GP care. The QOF took
priority over the other quality development initiatives like audit and peer review.
Nowadays, GPs try out new instruments of quality development as the Maturity Matrix.
The debate on indicators in the UK is important. Until now only process measures of
quality have been addressed. Moreover, although some doubts remain on the validity of
the clinical indicators: they may be too crude and not cover the entire scope of general
practice. In their review, Seddon et al. 44 also concluded that most studies using
indicators reported about chronic conditions whereas acute care, preventive care and
non-technical aspects of care were less considered.