My eye was drawn to a recent report in the media with the headline Questions raised over GP bonus system. It referred to the new research on the GP contract, whereby doctors received extra money for hitting certain performance targets – the Quality and Outcomes Framework or QOF payments. These can amount to one third of the GP's pay and has helped push the average to above £100k.
The study suggested that the bonus system has had no real impact on the treatment of high blood pressure.An international team of experts looked at high blood pressure measures, as well as how many patients ended up getting ill. But they found 'no discernible' benefit from the scheme, the British Medical Journal reported. There was little improvement that could be attributed to the bonus system, although there did seem to be a small improvement in the numbers getting treated.
They concluded: 'Good quality of care for hypertension was stable or improving before pay for performance was introduced. Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes. Generous financial incentives, as designed in the UK pay for performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions'.
The relevance of this study to dentists is that a similar framework, the dental QOF, will be piloted alongside the capitation pilots due to start this April. There is, however, one significant difference between the GPs' scheme and ours. Doctors received a bonus, but this time round the health department has learned a lesson. Dentists will have ten per cent deducted from their contract values, which will only be paid if they achieve their performance targets.
So what will the researchers of the future discover about the dental QOF and its effect on practices and patients. Perhaps we had better look at the proposals and see whether there are similarities with what is required from GPs. The significant fact in the BMJ research was that doctors were monitoring blood pressure in their hypertensive patients, even before they were paid the bonuses. So they were a reward for good practice, not an incentive to practise well.
The dental QOF has three elements, clinical, patient experience and safety. The last of these is easiest to deal with as it consists of only one item: do you update the patient's medical history each time they attend. Although the barrier is high, you should do this for 90 per cent of patients, it is something we surely all do. It is something drummed into us at dental school and attaching a small payment to it is hardly likely to change our behaviour, any more than similar payments did for doctors.
When you read it a bit more carefully though what it actually measures is whether 'an up-to-date medical history is recorded at each oral health review'. So it's all about paperwork, not patient safety. Much the same can be applied to
'patient experience'. There are seven questions the patient has to answer, including whether they can speak and eat comfortably, whether they were satisfied with the cleanliness of the practice and whether the staff looked after them well.
These are all good questions and they are increasingly common in life from companies as diverse as hotels or online book sellers. The reason such organisations ask us is because they want to improve their service and keep their customers. Any successful practice needs to make sure that its patients are happy if it wants to stay in business. This is a far greater driver towards quality than the threat of having a few quid taken away from you if you don't achieve a target as measured through a patient questionnaire.
Lastly we come to the clinical effectiveness measures, which amount to 60 per cent of the payments. There are five measures here, three looking at 'active decayed teeth' at various ages and the other two looking for improvement in periodontal scores (BPE). All good stuff you may say and not unlike those that apply to doctors. But the research shows that making these payments has little effect on way that GPs work. So will they have any effect on the way that we dentists work?
Quality and outcomes are buzzwords for the coalition Government, not just in the NHS, but across the whole range of public services, except of course the administration of government itself. So to produce this dental Quality and Outcomes Framework, a committee was established including some wet fingered dentists provided by the BDA. I am sure a lot of work went into it and that it will be refined in the light of the pilots.
But the question remains, will it make a blind bit of difference to the way dentists work? Or is it just a box-ticking exercise to demonstrate that we have achieved certain centrally imposed targets? What will be the outcome of the quality and outcomes framework?