NHS performance ratings need an overhaul

10 August 2016

Performance measurements in the NHS are outdated and do not inform the public. The Quality and Outcomes Framework (QOF) is a case in point. This is a primary care pay-for-performance programme whereby GPs are financially rewarded for hitting targets. For a patient with cancer the targets are:

  • Practices keep a register of patients with cancer;
  • Patients with cancer should be seen in the practice within 6 months of diagnosis.

Research by Reform in April showed that 96.5 per cent of practices were hitting these targets. This is despite the UK having lower cancer survival rates than comparable European countries. In May the Lancet produced work looking at cancer survival rates since the introduction of QOF and compared these to other high income countries. It found that QOF had had no impact on mortality. Impressive QOF scores may be because GPs can remove patients that are difficult to manage from their ratings.

In secondary care targets are based around waiting times: the four-hour target in A&E departments to see, treat and admit or discharge patients and the two-week cancer referral pathway. These are honourable ideas and instinctively feel like they improve patient journeys.

The problem is that these targets quantify activity not outcome and outcome is what matters. Though QOF tries to measure quality; it actually measures compliance with guidelines. A patient with cancer will mind less about the register their GP has and more about their chances of survival.

In 2014, the government took a step towards improving transparency and gave patients access to outcomes data by introducing the website “My NHS”. The website has some information about survival rates following surgery and patient satisfaction but there are limitations to the amount available to patients and many trusts have large gaps in their data.

One way of measuring outcomes would be to look at specific conditions. For patients with cancer, it is perhaps more relevant to measure the staging of disease at the time of diagnosis; the quality of life and the survival rates. By publishing this data patients can make informed decisions about their provider and this extra layer of competition will drive up quality.

Having taken control over their health and social care budget, Manchester has set out a new system to measure outcomes. It moves away from QOF and aims to assess everybody including “the silent thousands” – those who are difficult to reach and difficult to manage. The approach is to “Start Well, Live Well and Age Well.” Specific outcomes include children reaching good levels of development; families being economically active and elderly people being supported to stay well and live at home. These are measures the public can relate to and these are the kind of outcomes by which the NHS should be judged.

Kate Laycock, Researcher, Reform



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