QOF Fiasco 2: ’Immoral’ refusal to learn from mistakes

By Jerome Burne

Last week I wrote about the great QOF (Quality and Outcomes Framework) fiasco – the 30-billion-pound public health experiment involving the whole UK population without any kind of testing or pilot programs and without telling patients (in any formal sense) what was going on. Ten years after its launch it was clear that it had almost totally failed. Yet almost no one outside the profession knew about it. 

Given its potential impact on our health, this seemed a major scandal that warranted rapid action and proper investigation.  This week’s post is about the medical establishment’s remarkable ability to ignore the implications and refusal to do anything about it at all. This failure to even attempt to learn any lessons from it has been described by one professor of public health as a ‘frankly immoral way to conduct policy.’

The policy wasn’t specifically kept secret but the key part of the program – paying GPs for testing for certain health biomarkers and then for prescribing various drugs if they fell above or below them – came as shocking or surprising news to those who did accidently learn about it. That accounted for half the cost, the other half went to pay for the increase in drug prescriptions.

Tiny bang for big  bucks

The original purpose was not specifically designed to benefit patients – although it was assumed it would – but to solve a trade-union style struggle between GP’s and the government over working hours and wages.

The revelations about QOF are contained in an excellent new book by GP and Telegraph medical columnist Dr James Le Fanu called ‘Too Many Pills: how too much medicine is endangering our health and what to do about it’.

The kicker was that when this vastly expensive and untested project was studied to see if it had delivered bangs for the mountain of bucks – drop in chronic diseases, drop in hospital admissions and as many as 30,000 lives saved (statistically literate readers will know you don’t actually save lives, you increase time till death), the report in the Lancet  found there was virtually no benefit.

Now you might think, given persistent NHS underfunding, that spending vast amounts for years with no benefit would be a matter for intense professional and parliamentary scrutiny. The latest headline story is that every household will be faced with a 2000-pound tax bill to keep the service afloat. But so far as I can make out, the profession is intensely relaxed about it, while MPs, like everyone else, are pretty much in the dark.

No one is to blame; back to the drawing board

But why did things go so badly wrong? The Lancet article made it clear the program had been a comprehensive failure: ‘Our results show that the introduction of the QOF was not associated with significant changes in mortality for the diseases targeted by the program.’

One reason for the lack of any outcry is the wildly implausible but reassuringly vague explanation for the failure that the researchers came up with. This made it sound like an admin problem that could be dealt with. A more obvious explanation, which they ignored, is that prescribing an increasing number of drugs to the whole nation to stop them getting ill, isn’t effective.

But attributing the failure to something so fundamental has huge professional and financial implications. So instead, it would seem, they claimed that the reason that QOF didn’t work because the policy of paying doctors to diagnose and treat just didn’t get results. Brilliant. No one’s fault. Just one of those things. Back to the drawing board to find a better way to deliver those drugs.

But the explanation makes no sense – all the drugs prescribed had ‘gold-standard’ RCT’s showing they were safe and effective at cutting disease risk. The effect of QOF had been to treat many more people, providing a better chance of achieving a favourable result.

Maybe unreliable RCTs were the problem

Doctors are trained to gather symptoms which then point to a diagnosis that can be treated with (usually) a drug. There is no suggestion they prescribed fewer drugs under QOF, in fact prescriptions doubled in ten years. So how did the payments make the drugs less effective?

Could it be that, heretical thought, those big RCTs weren’t as reliable as their abstracts reported? Dr Fanu provides evidence for how small the benefits from some of the block-buster drugs like statins could be. This was covered briefly in last week’s post.

Given that the Lancet’s explanation for the failure didn’t make sense I wondered if any of the later studies on QOF had come up with anything more plausible. I found another post mortem published in 2017 in the British Journal of General Practice (BJGP). 

It found a few marginally more positive results, such as a ‘modest’ slowing of emergency admissions and an improvement of diabetes care. However, the researchers pointed out that they couldn’t be sure that the improvements were caused by QOF.

QOF not holistic; no surprise there

The overall picture was just as disastrous. Saving lives had been one of the expected outcomes but there was ‘no evidence of a drop in mortality rates.’ The explanation that QOF was the faulty implementation of a perfectly good policy still didn’t make sense.

However, the paper does hint at another reason for QOF’s failure. It reported that the policy had had no effect on some of the other goals of treatment that the NHS has recently signed up to, specifically: ‘co-ordination of care, holistic care and self-care.’

But that’s not at all surprising. Did anyone expect it to? GPs get a point for identifying a patient as obese – weighing them – but nothing for implementing a program that helps them lose weight. QOF is essentially a tick-box exercise designed to get the same drugs into patients who have the same disorders. That is the opposite of holistic and self-care approaches which aim to address issues specific to each patient.  

The one-size-fits all model that QOF embodies penalised many GP practices and various groups of patients such as students. Dr Tony Butler GP for 36 years explained how it worked. Patients in each geographical area were shoe-horned into a mathematical model that set the levels for a range of factors affecting health, such as how common various diseases were, numbers in various age groups and the degree of poverty and social deprivation. Inevitably many GP practices didn’t fit the estimated norms.

Failing to find patients that didn’t exist

‘My practice had a large number of students, so we were heavily penalised for not having enough patients with heart failure,’ said Dr Butler. ‘It was assumed that we were not screening our practice population hard enough to find them, even though such patients did not exist in our area.

‘Meanwhile, we got very little QOF funding for our student patients who did exist, because we didn’t officially have them. This is still the case today at a time when we are concerned about the mental health problems and provision of adequate mental health care and student support in Universities.’

So, plausible reasons for QOF’s failure would include: a rigid and inflexible structure that often didn’t reflect what was happening in the real world and contributed nothing to things like self-care and a holistic approach. Also worth considering is that that putting more people on more drugs for prevention may not be an effective public health policy.

This notion the QOF wasn’t designed to cope with the individual needs of patients is backed up by the recommendations set out in the BJGP article. First it says that the profession needs to consider ‘what high quality primary care is’ and then to find ‘other ways of ‘motivating primary care (rather than paying them) to deliver it.’

Relaxed official attitude to QOF’s many problems

If GPS really don’t know how best to keep us healthy and would need extra incentives to do it, that surely means a radical restructuring is needed and fast.

But there is no sign of this. In 2015 The Royal College of GPs had called for QOF to be replaced so GP’s could do more holistic care. A year later NHS England declared that ‘QOF may have served its purpose’. That year Scotland did actually abolish it.  Earlier this month (May) the General Practice Committee of the BMA (British Medical Association) reported that a review of QOF was ongoing and that it would ‘describe a range of options’ for replacing it.

But this wasn’t going to be a rush to judgement. There was no expectation that there would be any change until 2020’ This might not matter if the challenge was simply to dream up alternative ways to keep GPs pay topped up – the RCGP’s report warned against abolishing QOF without ‘assuring GPs of a stable income’ because that would be ‘likely to have detrimental effects on patient care’.  While deliberations about what exactly constituted good primary care obviously shouldn’t be rushed.

Meanwhile GPs continue to receive their incentives and patients are still being handed the additional pills even though the evidence is they aren’t benefitting. We also don’t know how or why it went wrong or what needs changing as a result because no attempts are being made to find out.

A cycle of ignorance that is unfortunately typical

‘It is frankly immoral to conduct policy in this way,’ comments Tom Marshall Professor of Public Health and Primary Care at the University of Birmingham, commenting on an article in the BMJ earlier this month (May 2018). 

What he was particularly critical of was the lack of any attempt to evaluate its effectiveness at the start and now the possibility that ‘it will be removed without evaluation of the effects. This cycle of ignorance is unfortunately typical in health policy.’

What makes the failure to investigate worse is that QOF is set up in a way that is designed to allow data to be collected, making it relatively easy to evaluate. Professor Marshall suggests there needs to be a comparison between QOF and non-QOF areas. ‘Rather than a blanket end to the policy It, should be withdrawn in some geographical areas and not others.’

It is bad enough that QOF cost a fortune for virtually no benefit, to fail to learn from its mistakes represents an abandonment of evidence-based medicine on a scale that should trigger official enquiries to find out who knew what and when.

Jerome Burne

Jerome Burne

Jerome Burne is the editor of HealthInsightUK. He is an award-winning journalist who has been specialising in medicine and health for the last 10 years and now works mainly for the Daily Mail. His most recent book “10 Secrets of Healthy Ageing” was written with nutritionist Patrick Holford. He blogs at “Body of Evidence” – jeromeburne.com. 2015: Finalist for 'Blogger of the Year' award from Medical Journalists' Association.

7 Comments

  • Your article was timely as I attended the NICE Review Scoping Meeting on Friday for ME/CFS to replace NICE CG 53 – a hot topic since 2007….Page two of the slide presentations issued to us on Friday;

    What does the scope do?
    Ensures the guideline addresses the key areas of variation in delivery of care and quality

    How on earth can this be achieved? There appears no formal mechanism for feedback to NICE about “variation”, care or quality!!.
    NHS England and NHS Public Health have not addressed this.

    Government (D o H and SC) don’t collect data on ME CFS Services-
    Not all services subscribe to “BACME”-
    One of the informed stakeholders involve in NICE before and with BACME (medic) gave out some statistics which are not common knowledge (only 9% of services have a lead ( consultant level?) physician) , most are therapy OT and Physio led; annual average “spend” on a MS patient £80, and ME patient averaged at £4 I think she said (will have to check).

    I suggested “Counting the Cost” Report could help inform?
    http://2020health.org/2020health/Publications/Publications-2017/OHC.html

    Also the APPG Inquiry (aborted) on Barriers to Access of Social Care.

    She was pressing for some “outcome measures”…..to guide the debate and NICE- If she meant “Friends and Family Test, (F&FT) “, forget it!
    We pressing for some robust Key Performance Indicators for our area but the KPIs suggested we were told were too demanding (ie too revealing).
    But even our statistical analysis of the F& FT revealed a worrying decline and reduced satisfaction year on year.
    More worrying was the failure to deliver contactual obligations and that was not just waiting times…..with absolutely no consequences for the offending service from the commissioning teams.
    Care Quality Commission deliberately ignored complaints too and refused to look at inspection.

    So, when this came up today, I thought back to Friday………
    http://healthinsightuk.org/2018/05/28/qof-fiasco-2-immoral-refusal-to-learn-from-mistakes/

    QOF Fiasco 2: ’Immoral’ refusal to learn from mistakes

    • Editorial

      Yes it is clear that the medical system is designed with a one-way communiction system – top downwards. When it was set up patients were grateful and obedient and doctors were knowledgeable. Now there are many well informed and articulate patients and independent researchers who are still regarded as an irritant instead of an ally as would be the case if healing patients was heading the agenda.Frustration with official guidelines and the impossiblity of patient affecting them shows up in various areas such as ME/CFS, low thyroid, low fat guidelines. The collapse of QOF must have affected millions but almost no patients know anything about it – yet!

      • “Yes it is clear that the medical system is designed with a one-way communiction system – top downwards. When it was set up patients were grateful and obedient and doctors were knowledgeable”

        Acute care models based on directive interactions between providers and patients are simply ineffective in caring for those with (or at risk of) chronic disease.
        See my mini-review J Med Therap 2018 doi: 10.15761/JMT.1000130

  • I am eternally grateful that we in Australia do NOT have your QOF debacle.
    But we DO have doctors and specialists who are equally ignorant and in the thrall of Big Pharmacy.
    Preventative or ‘Life-style’ (read: Diet & Exercise) advice is risky for a GP to give his patients, – the Accredited Dieticians mafia will go for his jugular with official complaints to our regulatory agency. They’ve succeeded in silencing more than one Physician.
    On the plus side, dietary commons sense such as LCHF is becoming so widespread in the Great Unwashed, that it’s difficult to un-see the positive results in chronic metabolic disorders like T2 Diabetes / obesity / CVD
    If I wasn’t such a cynic, I’d guess the continuance of QOF has more to do with the Public Service looking after the vast army of employees, not the patients.

  • Dr Le Fanu’s book includes an excellent chapter on statins. He rightly makes the point that there is little or no informed consent for a medication with such insignificant ‘benefits’ and still largely denied harms.

    The lack of any informed consent is a scandal that no one in a position of authority seems to care about. Almost no one would take statins who knew the statistics, so the issue has to be pushed quietly to one side. Isn’t treatment without informed consent supposed to be a crime?

    Every doctor should lift their gaze from the computer and Nice Guidelines and take a look at the evidence. ‘Too Many Pills’ offers the kind of good sense and judgment that seems to be increasingly rare in medicine.

    • Yes, I read that book too. One thing that amazed me was that concepts like ‘treating the herd’, or ‘the population is sick’ were (and presumably still are) taken seriously. I’d thought they were jokes from the anti-statin camp!

      Sometimes I feel as though press freedom is a thing of the past – why isn’t the QoF scandal being reported in the health section of every newspaper? Why isn’t there a Panorama program on this issue?

      • I agree, David.

        It is very odd how relatively trivial issues in comparison receive vastly more coverage. Somehow we’ve become used to ‘medicine’ killing and harming so many people. How many pharma Grenfells are there each week? Losing your memory, mobility and health doesn’t seem to have the drama required to sustain media interest.

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