I think the QOF stands as the most successful health reform, in its own terms, the NHS has ever had. What I mean by this is that it was designed to achieve a range of behavioural changes in GP practices through the introduction of its linkage between funding and points, and met those goals spectacularly well.
If I were cynical I might say that the lesson from the QOF is that we should withhold funding from doctors unless they conform to pre-agreed clinical frameworks. But I’m not entirely cynical, I think that’s only part of the picture. I think there are several more important insights about achieving change that come from the QOF.
First, the key thing about the QOF targets is that they were agreed in negotiation with the GPs first. There is dispute about whether they are evidence-based or not, but by agreeing the targets, they have become accepted within the profession as targets that are broadly legitimate. They are certainly more legitimate than the much broader, and largely centrally-imposed targets that are imposed on hospitals, and often resulted in ‘gaming’ as a result (see Hood, references below).
Second, by being specific and practice-based, the targets were seen as things which could be incorporated into the everyday life of GP practices rather than being about things over which clinicians had little or no control – again as was often the case with the targets used in hospitals.
Third, GP practices were given autonomy on how they met the QOF targets. Some made wider use of nurses or practice managers, in some cases GPs took on the work. Instead of saying how the targets would be met, practices had discretion and autonomy in working this out for themselves.
What all this adds up to is a process by which targets were pre-agreed, accepted as being legitimate, incorporated into the practice of care, and with practices working out ways of managing the load. The result was the targets being met spectacularly well. In NHS terms this is a remarkable result – can you think of a reform which has worked as well in achieving behavioural change.
Now some researchers reckon the QOF was a waste of money as it hasn’t led to improved patient outcomes, just to targets being met. I’m not a clinician, so can’t separate these out. But either way I think it offers us lessons for how we can better achieve behavioural change in the NHS elsewhere – there’s no reason why clinical teams in hospitals can’t set targets themselves and go after them in similar ways, or for managers to reward them for hitting targets in similar ways to the QOF. I’ve always been a bit baffled by NHS managers saying it was a mistake to drop targets after the 2010 election – if they felt that strongly they could always have kept them themselves – it’s up to them how they they run their hospitals – they don’t need the Secretary of State to tell them!
In all then, even if you don’t buy that the QOF has made things better for patients, it offers us valuable lessons on how to do the management of change. Wouldn’t it be good if we could focus on learning these lessons rather than spending our time having to deal with daft NHS reforms?
Some references about the QOF and targets
Checkland K, Harrison S, McDonald R, Grant S, Campbell S, Guthrie B. Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract. Sociology of Health & Illness. 2008;30(5):788-803.
Edwards A, Langley A. Understanding how general practices addressed the Quality and Outcomes Framework of the 2003 General Medical Services contract in the UK: a qualitative study of the effects on quality and team working of different approaches used. Quality in Primary Care. 2007;15:265-75.
Hood C. Gaming in Targetworld: The Targets Approach to Managing British Public Services. Public Administration Review. 2006;66(4):515-21
Maisey S, Steel N, Marsh R, Gillam S, Fleetcroft R, Howe A. Effects of payment for performance in primary care: qualitative interview study. Journal of Health Services Research and Policy. 2008;13(3):133-9.
McDonald R, Harrison S, Checkland K, Campbell SM, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. BMJ. 2007;334(30 June):1357.