Making exception: 1 - Why?

Exceptions have to be one of the most contentious issues in the QOF. Considered essential to many practices and built into the very fabric of the QOF. However it seems that few people other than GPs actually like them.

PCTs hate them as they have the vague and ultimately unprovable feeling that they may be being cheated. Statisticians hate them because it makes it very difficult to say what the real results are for the practice population. Certainly this latter argument misses the point somewhat. The point, of course being that they make the QOF rather saner than it would be otherwise.

This is not to say that there are not things that can be learnt through the exception reporting and it is those issues that I will explore over a series of articles. The actual nitty gritty of dealing with them I will leave to another day and for the moment concentrate on the question of "What are they for?

1. Patients who have been recorded as refusing to attend review who have been invited on at least three occasions during the preceding twelve months.
2. Patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances e.g. terminal illness, extreme frailty.
3. Patients newly diagnosed within the practice or who have recently registered with the practice, who should have measurements made within three months and delivery of clinical standards within nine months e.g. blood pressure or cholesterol measurements within target levels.
4. Patients who are on maximum tolerated doses of medication whose levels remain sub-optimal.
5. Patients for whom prescribing a medication is not clinically appropriate e.g. those who have an allergy, another contraindication or have experienced an adverse reaction.
6. Where a patient has not tolerated medication.
7. Where a patient does not agree to investigation or treatment (informed dissent), and this has been recorded in their medical records.
8. Where the patient has a supervening condition which makes treatment of their condition inappropriate eg cholesterol reduction where the patient has liver disease.
9. Where an investigative service or secondary care service is unavailable.

The current criteria are listed in the box. Their actual number seem to vary from source to source but this is more about layout than content. What is quite apparent is that they are designed to keep the QOF relevant. Some are about not penalising practices for patients informed decisions, something that had controversially not been included in the childhood vaccination targets. In a similar vein other exceptions are there to make sure that GPs are not encouraged to give treatments that are inappropriate or even harmfull. Finally some of the exceptions allow some time for the number to be produced after diagnosis or registration.

All of these codes provide a valuable services to prevent inappropriate care being incentives. There have been some calls for the abolition of exception codes though. There are some who would argue for the abolition of the codes, sometimes arguing that the fact that the points only score up to an achievement of 90% or less does the same job. The reality is that this latter mechanism is a blunt instrument, unresponsive to local circumstances. If anything it is these top thresholds that should be abolished with a continuation of the scoring up to 100%. It is a bizarre system that encourages clinicians to get to 90% and then stop.

It is however very clear that GPs are not stopping at the upper thresholds. Most of the achievement on this site is well over these thresholds. Exception reporting is essential in removing undue pressure on patients to conform to the medical model. It is probably the easiest target of cheap shots against QOF but the alternatives are likely contain more perverse incentives.

Having made the case for their existence, next time I will look at how they are implemented in practice by both practices and the business rules.