status quo of quo vadis? - KCE

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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.
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 41 2.5.5 France: an outlier France appears as an outlier in the literature review. Many initiatives were set up with a low support of the professionals. National laws exist but no national policy seems to work till now. Probably the ‘Evaluation des Pratiques Professionnelles’ will be the future for improving the quality of the practices. The lack of peer-reviewed literature on the quality initiatives makes the evaluation of the system more difficult. 2.5.6 Conditions for implementation The choices for quality development methods depend on the national culture and legislation: the findings of the literature may therefore not easily apply to the Belgian situation. For instance, the introduction of a system similar to the UK-QOF project requires major structural changes like for example changing the professional culture, building a powerful IT main frame, ensuring data transmission from the practice to third parties and reforming the payment systems. The budget impact is a major issue: the UK experience shows that the initiators of the system underestimated the results of the GPs and therefore the financial budget linked to the QOF. In some countries, GPs have to adopt the quality debate within their practices because of an increasing competition and pressure from external bodies. In these countries, general practice is more subject to open market values. In Germany, the contracts between physicians and health insurers stipulate the need for quality development procedures. In Australia, large-scale commercial general practices create an increasing competition where quality might play a role. The Netherlands developed a competition for contracts with insurance companies. In the future, insurance companies may select GPs based on their enrolment in the practice accreditation scheme of the NHG. Conclusion of the literature review on quality system in foreign countries • A comprehensive framework, either summative -rewarding targets as in the UK- or formative as in Australia is a pre existing condition for a quality development system. • Leadership and collaboration with governments, a strong system support (either national or regional), support of individual practices and financial incentives must be addressed. • Countries that succeed in effective quality development systems have national well performing and efficient IT system for routine data collection, extraction and data management by trustworthy third parties. • There is a lack of evaluation of the effectiveness on patients’ outcomes. The evaluation of any system, when available, relies on soft or intermediate endpoints like patient satisfaction and physicians’ opinions. • There is a lack on data on the cost-effectiveness of all quality systems.
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