Tag Archives: QOF

“The best of times, the worst of times” for general practice

Roger Jones

Roger Jones

Roger Jones is Emeritus Professor of General Practice at King's College, London and is the Editor of the British Journal of General Practice.
Roger Jones


quotefancy-359812-3840x2160As well as signalling the end for QOF, the keynote speech at the National Association of Primary Care by Simon Stevens, chief executive of NHS, was a ringing endorsement of his strong support for general practice. Newly and handsomely bearded, Stevens confirmed that this new investment in general practice of £2.4 billion will be made by 2020, and encouraged the audience to “rattle the cage” to make sure that the promises made for additional funding for primary care are honoured in the CCGs’ investment plans and in the Sustainability and Transformation Plans, which are currently being written.

It seems to me that Stevens has “got” general practice for some time – he repeated the now-apocryphal quote from a BMJ editorial: “If general practice fails, the NHS fails” – and, according to him, the Department of Health has got it too. They have moved from denial, through acknowledgement, to the “action stage”. He went on to give a very upbeat assessment of the range of interventions that are currently being made to turn the service around – in a nice analogy he suggested that general practice is not an oil tanker, but a flotilla.

First of all recruitment – and he reported early signs of positive effects of programmes of work being undertaken in the medical schools to encourage students and medical graduates to see general practice as an attractive career choice. There will be an additional 1500 medical students in UK medical schools before long, and the challenge of keeping general practice teaching and departments of primary care on their radar is not inconsiderable.

Stevens also thought that there were some early signs of improvement in the numbers of returners to general practice, and recognised that for them, as well as for other GPs, such as those working in out of hours services, medical indemnity costs were proving significant barriers. He announced, in the speech, that £5 million or “whatever it takes” will be made available so that GPs are not “on the hook” when wishing to work at night and weekends.

He is very keen on expanding the non-clinical, non-traditional workforce in primary care. He reported that 485 clinical pharmacists are now working in the NHS, with 500 more planned each year for the next three years. There is funding for 3000 more mental health therapists, and 22 areas are already benefiting from this additional resource. He strongly endorsed the importance of practice nurses, practice managers and receptionists, and the importance of providing resources for external training and support for them.

He described the “Time to Care” programme, including 10 changes that can make a real difference to practices, such as dealing with the delays and costs associated with continued re-referring of patients between primary and secondary care. He also reported that over 800 vulnerable practices have been involved in the BMA/RCGP practice resilience program, and also recognised the importance of improving the built environment for general practice. He said that 560 practice improvement schemes have been completed, as part of the GP Infrastructure Scheme, with 316 in train, and 300 more announced on the day of his speech.

The Primary Care Home was a strong theme of the entire conference, and was touched on by Stevens, the report that this concept is being developed in 77 locations, where it may be possible to square the circle between this type of base general practice and the need to work at scale.

And it’s true – Stevens did say that this is the end of the road for QOF, which he said was “now nearing the end of its useful life”, and had descended into a box ticking exercise. New voluntary contracts are being developed as alternatives to current pay for performance arrangements.

Stevens was remarkably candid during an extended question and answer period. He was asked when the government would wake up to the need to charge patients to see their GP, and he replied that this was not what the country wants, and he had no intention of introducing charges. He was pressed by a GP registrar on how general practice was going to become a more attractive career option and by me on how he might turn the tide of early retirement, which is contributing to the workforce crisis. The answer to both is, of course, to be positive about the important role that general practice is going to play in the NHS of the future, the new opportunities for developing new ways of working, and achieving a better balance between work, family life and leisure. He also acknowledged that in important disease areas such as cancer and cardiovascular disease the NHS does not perform well in comparison with many OECD health systems, and recognised that much more will need to be done about early cancer diagnosis and cardiovascular prevention and disease management. Let’s hope that the oil tanker/flotilla analogy works, and it is possible to see some early “quick wins” in time to turn the tide.

Quality indicators for child health in the UK

Peter_Gill_Peter Gill is a paediatric resident at The Hospital for Sick Children in Toronto, Ontario and an Honorary Fellow at the Centre for Evidence-Based Medicine at the University of Oxford. Follow Peter on Twitter @peterjgill

In the December 2014 issue of the British Journal of General Practice, several colleagues and I published a set of paediatric quality indicators for UK primary care.[1] The paper represents the main findings from my doctoral thesis completed under the supervision of Prof David Mant and Anthony Harnden at Oxford University. It is exciting to see the paper in print (it provided a morale ‘boost’ after working a stretch of nights) accompanied by a thoughtful editorial.[2] But having returned to the ‘coal face’, I am reminded of the integral role of quality indicators in clinical practice.

Why develop indicators?

Caring for children is an important part of UK general practice yet several studies have demonstrated that care quality can be improved. However, only 3% of Quality Outcomes Framework (QOF) markers relate to children and there is no set of child-relevant indicators for UK primary care. For years, the call to develop and integrate child health indicators into QOF has fallen on deaf ears despite evidence that leaving out indicators probably has negatives consequences for care quality. Therefore, we sought to develop a set of quality indicators for children and adolescents which cover a range of paediatric care and reflect existing UK evidence-based national guidelines.

What did we do?

In just over 2000 words, the BJGP paper outlines how a set of 35 indicators were developed; it looks deceiving simple. In reality, the study is the culmination of five years of work with invaluable contributions from many (including funding bodies). First, we selected priority areas [3] after searching the evidence [4], evaluating unplanned hospital admissions [5] and interviewing GPs [6]. Second, we reviewed NICE and SIGN national guidelines relevant to children in primary care before translating key guideline recommendations into quality indicators. Third, a UK-wide panel of GPs with a special interest in child health assessed the validity and implementation of indicators using the RAND methodology.

We believe the 35 indicators have high levels of clinical support, reflect national guidelines, and could be feasibly implemented in the UK. Rather than narrowly focus on easily measurable aspects of care, we address broader determinants of child health outside of clinical guidelines (e.g. child safeguarding and professional development) and prompt GPs to critically reflect on their actions (e.g. rationale for antibiotic prescribing).

How can the indicators improve quality?

There are many ways in which the care quality can improve with implementation of the indicators. For example, the indicators may lead to the earlier diagnosis of easily missed conditions such as Coeliac disease and Type 1 Diabetes which may improve quality of life and reduce complications. In 2008, there were 6300 paediatric medication related safety incidents; the prescribing indicators may improve medication safety. Appropriate evidence-based management of common conditions such as asthma, may reduce emergency department visits and secondary care referral. Each indicator, after appropriate piloting in general practice, could potentially play an important role to improve care quality and identify which areas require increased attention.

What next?

The NHS is an exemplary model of a health system with robust primary care. But, at the risk of being cliché, any system is only as strong as its weakest link. Quality indicators, whether linked to QOF or used as an audit tool, must cover the full range of UK general practice. The on-going restructuring of the NHS may only further marginalise the care of children and adolescents whose interests are often poorly represented.

These quality indicators provide a starting point. They are a set of tools for clinicians working with children. What we need now is for individuals to pick up the tools and get to work. In the US, primary care indicators were signed into law by President Obama in 2009 through the Children’s Health Insurance Program Reauthorisation Act. Why are there not similar initiatives in the UK? Bold steps are needed to implement paediatric indicators in UK primary care.

[bctt tweet=”BJGP Blog: Bold steps needed to implement paediatric indicators in UK primary care.”]

The paper is Open Access and available at http://bjgp.org/content/64/629/e752



1.     Gill PJ, O’Neill B, Rose P, Mant D, Harnden A. Primary care quality indicators for children: measuring quality in UK general practice. Br J Gen Pract. 2014 Dec;64(629):e752-7. doi: 10.3399/bjgp14X682813.

2.     Dowell A, Turner N. Child health indicators: from theoretical frameworks to practical reality? Br J Gen Pract. 2014 Dec;64(629):608-9. doi: 10.3399/bjgp14X682585.

3.     Gill PJ, Hewitson P, Peile E, Harnden A. Prioritizing areas for quality marker development in children in UK general practice: extending the use of the nominal group technique. Fam Pract. 2012 Oct;29(5):567-75.

4.     Gill PJ, Wang KY, Mant D, Hartling L, Heneghan C, Perera R, Klassen T, Harnden A. The Evidence Base for Interventions Delivered to Children in Primary Care: An Overview of Cochrane Systematic Reviews. PLoS One. 2011; 6(8): e23051. doi:10.1371/journal.pone.0023051

5.     Gill PJ, Goldacre MJ, Mant D, Heneghan C, Thomson A, Seagroatt V, Harnden A. Increase in emergency admissions to hospital for children aged under 15 in England, 1999-2010: national database analysis. Arch Dis Child. 2013 May;98(5):328-34. doi: 10.1136/archdischild-2012-302383.

6.     Gill PJ, Hislop J, Mant D, Harnden A. General practitioners’ views on quality markers for children in UK primary care: a qualitative study. BMC Fam Pract. 2012 Sept 14;13(1):92 doi:10.1186/1471-2296-13-92.