Nye Bevan once argued that, if you want a GP to do something, you should write the instruction on the back of a cheque. Incentives, introduced in the GP contract negotiated when John Reid was Secretary of State, have proved to be a powerful incentive in primary care shaping professional behaviour and catapulting some hitherto under prioritised issues to near the top of the primary care agenda.
Yet the Quality and Outcomes Framework (QOF), introduced to incentivise higher quality primary care, also demonstrates the importance of structuring incentives carefully: put simply, a poorly constructed incentive can lead to all sorts of unintended behaviours. Focusing incentives on outcomes is one way of achieving this, but is easier said than done. As Greg Penlington wrote on this blog, many of the measures used in quality standards focus on process rather than outcome. This has also been a challenge in the QOF and, as the Government sets about expanding the use of incentives, both on commissioners and providers in primary and secondary care, it would do well to learn some lessons from the QOF experience.
Over time, the process for determining the QOF has become more and more independent, with a stronger emphasis on clinical evidence. Yet the QOF has never truly escaped from its origins – a contractual mechanism for remunerating GPs. Even today, a rigorous and lengthy process led by NICE leads to what is essentially an industrial relations negotiation: dry evidence gives way to a deal in a smokeless room. NICE’s recent recommendations on changes to the QOF could easily be ignored in the negotiations. In incentivising primary care, evidence only goes so far.
NICE was first given responsibility for the QOF following a row about exactly this issue. Well thought-through indicators on peripheral arterial disease and osteoporosis were squashed by a great clunking fist. During his leadership election coronation Gordon Brown had promised to extend GP opening hours. With no additional money available to pay for it, resources earmarked for new indicators in the QOF were instead diverted to compensate GPs for some weekend working. Clinical evidence was trumped by a political fix.
The simple truth is that, despite a somewhat laborious consultation process resulting in NICE developing a new process with all the thoroughness which is the hallmark of the Institute, the same thing could happen again. NICE may write the menu, but the negotiators are in charge of what to choose.
Yet the latest batch of recommendations has also revealed the other side of the equation: a rigorous evidence-based process is, well, rigorous and evidence-based. There is little scope for innovation or flexibility to tackle an emerging health problem (if the solutions to these had lots of evidence underpinning them then they might not be a problem in the first place). The result of this is that NICE has recommended that all the depression indicators be ‘retired’ (quaint word for scrapping) on the grounds of poor evidence for their impact. This has been met with predictable fury by depression campaigners and bewilderment by the NHS, coming at a time when the mental health outcomes strategy was meant to herald a major push on the issue. Even NICE seems less than effusive about its decision, with Andrew Dillon writing to the negotiators admitting that this may “reduce the quality of care” in advance of the development of any new indicators. The political danger inherent in leaving a gap in incentivisation has apparently been recognised by the Department of Health, which has suggested to NICE that new indicators for a disease should be developed before others are retired.
It is hard to escape the conclusion that the QOF process has ended up with the worst of all worlds. Prone to the vagaries of a collective bargaining, it has been shorn of the flexibilities afforded by a less rigorous system for assessing evidence. Also, the GP community, through the BMA, has proven to be a highly effective negotiator of the QOF. Indeed, some may say it has been too effective, resulting in GPs being paid for doing things which were a core part of the job anyway, leading to fewer than expected health gains for the expenditure incurred. The National Audit Office found that ‘overachievement’ on the QOF was a major reason for overspend on the overall contract.
The Department of Health will need to avoid repeating these mistakes as it seeks to develop the CQUIN framework for providers and the Commissioning Outcomes Framework for clinical commissioning groups. Otherwise it could land itself with an expensive, cumbersome process which is still prone to the uncertainties of a negotiation it cannot control.