GP Targets Are Not Meeting Patients' Needs, UK

Main Category: Primary Care / General Practice
Article Date: 26 Nov 2007 - 0:00 PDT

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GP performance targets could be leading to lower levels of health care for those who need it most, argue experts in this week's BMJ.

General practice in the UK has the largest healthcare pay for performance programme in the world - the quality and outcomes framework (QOF). Practices earn points for the services they provide and these points attract financial resources into the practice.

The system has been hailed as a success for quality of care. But, while there have undoubtedly been useful achievements, Dr Iona Heath and colleagues warn that the system may not be meeting patient's needs.

Clinical care needs to be tailored to individual patients rather than using a mechanistic approach, they say. Yet they believe that the quality and outcomes framework diminishes the responsibility of doctors to think, to the potential detriment of patients, and encourages a focus on points scored, threshold met, and income generated.

The framework also needs to include clinically important outcomes, rather than concentrating on treatment processes, they add.

One of the aims of the framework is to tackle health inequalities but they warn that it has the potential to work in the opposite direction.

For example, marginalised and socially disadvantaged people are more likely to be listed as exceptions from quality framework payments and, once given that status, are at risk of receiving proportionally less attention.

In addition, as people living in deprived areas are sicker, more effort will be needed for doctors to reached fixed targets. Working in poorer areas therefore becomes less desirable, further reducing quality of care or even making care difficult to find.

Furthermore, there is evidence that payment for performance systems reward already high achievers and penalise low achievers and so exacerbate inequalities, they write.

Until the increase in process is translated into tangible outcomes, such as diabetes complication rates or incidence of heart attack or smoking related deaths, the benefits and cost effectiveness of the exercise cannot be established, they say.

Outcomes are much more difficult to measure than processes, especially at the level of individual practices, but the heightened emphasis on processes brought about by the framework should not be allowed to distract from the fundamental aims of medical care, they conclude.

Analysis: Measuring performance and missing the point?
BMJ Volume 335 pp 1075-6
www.bmj.com

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