What would David Cameron do?

Not the first question I would ask myself in any difficult situation but certainly has some relevance to QOF. Last week the Conservatives announced their new health policies. The one that interests us is "Outcomes not Targets".

Now it is hard to argue with that slogan. Outcomes are what matters. When it comes to drugs we are most interested in whether lives are saved or improved rather than exactly how much the blood pressure is changed or whatever. There is also no denying that most health targets are based more on process than outcome. In the QOF we have lots of targets about how often people have their blood pressure taken or an inhaler check and only one or two about any outcomes such as cholesterol or blood pressure readings.

So what to the Conservatives plan to do about it? Well all that is on their website is a show as a PDF - so there is not a lot of detail - but they do talk about putting the EQ-5D into the framework. If you are not familiar with the tool then follow that link for an example of the form. It is pretty short 5 question survey and at least appears to be easy to administer.

What is not clear is what happens next. For all the literature that I can find this is very much a research tool. There is not a lot of evidence for its use in general practice and what there is measures the patient rather than the practice. It would also be very difficult to separate out the effects of primary care, secondary care and social services.

It is probably a bit much to expect the fine details of implementation from a mid term opposition policy review. The answers to some questions would be nice though.

How is this translated into a points score and then (the final outcome) into cash? The score varies quite dramatically with age, sex and socioeconomic group. Paying for high health status would simply favour practices with younger and more affluent patients. Paying for health status improvements would reward practices starting from a low baseline rather than those who have worked hard in the past. Practices could also be 'rewarded' for a new housing estate or 'punished' for a factory closing. I will write and ask.

The Crazy World of Mental Health

For the vast majority of practices the clinical data on this site has been automatically extracted from their computer systems. There are various ways that this is done but it is all under the control of the business rules. These determine which codes indicate success or failure in each area and are thus crucial to practices. The original set of rules had a few quirks but these were fairly quickly ironed out and gave two good years of service. With the new, more complex, items in 2006/7 some more rules were needed. Nowhere was the change and complexity greater than in the mental health area. The diagnostic criteria changed from merely having a "severe and enduring" mental health problem to being exclusively psychotic and bipolar disorders. Also the individual criteria became quite involved - the worst being

MH7: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance.

There have been three sets of rules this year. Version 8.0 - in which the rules for MH7 were completely incomprehensible. Version 8.5 still had problems which I listed at some length and version 9.0 which was released shortly before Christmas. There is no doubt that version 9.0 is much better and solves many of the previous problems, albeit sometime in a somewhat cumbersome way. It does, however still have some problems and has introduced a new challenge to practices. Perhaps the most dramatic change is the abolition of the explicit mental health register. In the original QOF patients were given the option of 'opting out' of the mental health register. Under the new rules entry to the register will be coded on diagnosis rather than an explicit code. This is arguably a better way of doing things - in fact this is the way that the rest of QOF does things. But this is a very late rule change. Systems suppliers and central systems are not yet upgraded. Practices may have a very short time to make sure their data fits the new rules. Finally there is still no provision for the recovery from mental illness. Whilst much illness is lifelong there is a considerable amount that is short lived. Read code 212T means "Psychosis, schizophrenia + bipolar affective disorder resolved" which seems to suggest that active follow up would not be needed. Unfortunately the rules do not look for this code so some of my patients who only had a brief period of postnatal psychosis in the 1970s are included on the register. The solution has been to code them as 9h91 "Excepted from mental health quality indicators: Patient unsuitable". An ugly bodge maybe, and one that will possibly need repeating annually, but it does illustrate the use of exception reporting as a pressure valve for problems in the business rules. I await version 9.5 with interest.

The Billion Pound Database

There is a lot of discussion in the media about the increased income of GPs with even Mrs Hewitt wading into the debate. Once you get past the headline figures and the fact that a good part of the increase goes straight back to HMG as increased pension contributions you are left with the QOF income. If there was one condition which came with the investment in the NHS during Labour's second term it was that there should be verifiable results. These were always difficult to find for general practice and so the QOF was formed. Payment for the QOF follows sending in the statistics. Its is these numbers which receive payment and most practices have put in quite a lot of work to get them right. I have sat in innumerable meetings discussing discussing how things should be coded, spent many hours going back through records to make them visible to QMAS, performed over a dozen practice visits and have been on the receiving end of a couple. All of this takes time and I, in common with most of the UK population, don't work for nothing. Most of the work requires a reasonable amount of clinical knowledge so can be difficult to delegate. Like many GPs I am self employed - I don't have a salary for my work, I have profits. The government has decided to pay for statistics. Many GPs have spent hours polishing those statistics to a high shine for inspection and assessment. It is no surprise that profits have risen. The bigger question of the effect on clinical care is more difficult to assess as, almost by definition, there was not much data before QOF. What data there is greatly affected by the lack of incentive to code things. The only direct comparison that I have found is an audit of diabetes which shows some improvement but the effect is not terribly dramatic. In the end what the government really wanted was the statistics and they got them. So can you either browsing this site or downloading the billion pound database.

New! News!

There is quite a lot about the Quality and Outcomes framework that needs a home. There are, for instance, changes in the rules or announcements of prevalence figures that don't get to feature in the main dataset but may well be of interest to people browsing the site. This will also be a home to other bit of QOF information that I have written from time to time and have again lacked anywhere decent to put them.