The authors seem to work under the assumption that there is a payment system for GPs that will not create a conflict of interest, but I do not believe that this is the case: every payment system will have some negative impact on GPs behaviour: capitation based systems incentivise huge lists with little actual care, while systems that pay GPs for activity (such as, for example, in Germany or the US), create a bias towards ‘activism’, in other words, arranging lots of tests and investigations — and discourage spending time with patients for histories, examination findings, and explanations. Systems that pay every GP the same salary (as in Cuba or the former Soviet Union) are known to discourage doctors and can either lead to disengagement or to parallel earnings from private practice or non-medical activities.
Let's face it: GPs are only human, and collectively will behave as humans do, and a good majority will always be motivated by financial gain — this doesn't necessarily have to be selfish as such, but pressure to provide well for children and other dependants creates incentives of its own.
It can be argued that QOF could minimise the conflict of interest between professionalism and financial interest, by increasing pay for good practice and decreasing it for bad practice.
That this can't always work perfectly is obvious, and one way to address this is to constantly adjust it, keeping indicators that seem to perform well and removing those that encourage ‘gaming’.
What worries me is that there is no systematic way of gathering opinion from working GPs as to which indicators perform well: every self-respecting GP knows which of the indicators motivate us to improve evidence-based care (in my opinion, asthma reviews, blood pressure targets, epilepsy reviews, and several others meet this), and which ones encourage ‘gaming’ (one of the worst, in my view, being PHQ–9 for depression).
Why are jobbing GPs not more involved in developing QOF?
Notes
Competing interests
In our practice, I am nominally responsible for the depression indicators, but we have given up trying to achieve them.
- © British Journal of General Practice 2012