PROFESSOR HELEN LESTER
MB BCH MD MA FRCGP
Professor of Primary Care
National Primary Care Research and Development Centre
Helen is a GP in Birmingham and has been an academic adviser on the Quality and Outcomes Framework since 2005. She also leads a number of research projects on trying to improve the care of young people with serious mental illness
The Quality and Outcomes Framework (QOF), the most comprehensive national primary care pay-for-performance scheme in the world, was introduced in 2004 to both encourage evidence-based practice and act as a payment scheme for primary care.
Although a voluntary system, 99% of UK practices participate in the QOF, which originally consisted of 146 indicators (134 in 2010). Points for individual indicators were awarded in relation to the level of achievement of that indicator (eg, the percentage of people with diabetes with blood pressure below a defined target), with a graduated scale of payments that started above a minimum threshold (25% initially but raised to 40% in 2006) and ended once a maximum threshold (usually 90%) was reached.
Since 2004, the QOF has gone through one major (2006) and one minor (2009) reorg-anisation. In 2006, seven new clinical domains were added (depression, atrial fibrillation, chronic kidney disease, dementia, obesity, palliative care and learning disability) and the clinical points were increased to 655 (66% of the total points) within a slightly reduced overall framework of 1,000 points.
In 2009, the main changes were the addition of a new area of primary prevention for heart disease, making the clinical indicators worth 697 points or 70% of the framework. Three new sexual-health indicators were added to additional services, and changes were made to patient experience so that data were collected through a new national survey. Points for these changes since 2006 were largely released by the removal of a number of organisational indicators and the depth of quality measures.
For better or worse?
There are many indications that, since 2004, the QOF has improved primary care processes in terms of better recording of care, the use of evidence-based protocols in chronic disease management and in setting up more call and recall systems.
It has also, importantly, led to improvements in patient-level intermediate outcomes. A study measuring quality of care for three major chronic conditions in a representative sample of 42 general practices at two points before the QOF (1998 and 2003) and after the QOF (2005 and 2007) showed that quality was already improving rapidly before the QOF. When the financial incentives were introduced, care improved more rapidly for asthma and diabetes, and continued at the same rate of improvement for coronary heart disease.(1)
Subsequently, the rate of improvement tailed off, suggesting that incentives failed to operate once targets had been reached.(2) The overall conclusion was that the QOF has made a small but significant improvement to quality of care, over and above the multiple quality improvement initiatives introduced in the preceding five years.
The QOF also appears to have reduced inequalities in the delivery of healthcare. In its first year, median achievement rates for practices in the most affluent areas of England were 4.4% higher than for practices in the most deprived areas. However, by the third year this gap had narrowed to 0.8%. Poorly performing practices in deprived areas look as if they were just as able to respond to the incentives in the QOF as those in affluent areas.(3) In this sense, the QOF may be one of only a handful of equitable interventions in healthcare.(4)
Nonetheless, there are also a number of problems with the framework. There have been increasing calls for the QOF to provide better value for money,(5) and that few of the indicators are cost effective.(6) However, some of the problem here is that the majority of QOF clinical indicators are process measures and there is very little data to support a cost:benefit analysis.
There have also been a number of unintended consequences. While the QOF has led to changes in skill mix and teamwork that means practice nurses are now playing a far greater clinical role in many practices, there are suggestions that some nurses feel the greater emphasis on their technical skills and knowledge post-QOF is taking them away from their caring role.(7)
Many GPs are also concerned that the framework has adversely affected care by reducing time for patients’ concerns and encouraging a “tick box” mentality in the consultation.(8) These are not insignificant issues, although I would argue that healthcare professionals are trained to be able to integrate both the biomedical (the QOF reminder box in the corner of the screen) and the needs of the patient in front of them. Patients consult “little and often”, and there will be a number of opportunities to address the relevant QOF reminder, such as smoking status, over a 12-month period.
There are also concerns about the feasibility of some of the indicators, highlighting the fact that most of the existing indicators have not been piloted in a primary care setting, but were drawn up by clinical and IT experts.
What does the future hold for the QOF?
The QOF has succeeded in making quality improvement a core part of primary care and should, I feel, be retained as part of the payment mechanism for GPs. Some of the immediate challenges to the QOF in terms of worries about its cost-effectiveness and the validity of some of the indicators are being addressed by a new development process led by the National Institute for Health and Clinical Excellence (NICE).
Indicators are now piloted for six months in a sample of representative practices across the UK and are subject to a cost:benefit analysis before potential introduction. This new process started in April 2009 and the first results won’t be seen until at least April 2011, but I am certain that future indicators will be far more robust, with fewer clinical unintended consequences.
However, the overall proportion of general practice income dependent on the QOF should probably reduce, in part because of evidence mentioned previously of the disproportionate effect of the QOF on professional behaviour. Indeed, no other country experimenting with quality incentives is tying as large a proportion of income to quality of care.
This of course suggests that in future the QOF should be smaller, and is linked to current debates about how to remove indicators from the framework safely. Although indicators could remain indefinitely within the QOF, this would restrict potential benefits to a limited number of clinical conditions.
We also know that while the QOF effectively “kickstarted” care above secular trend for people with asthma and diabetes, this lasted only for a year or so. Data suggest that achievement levels in some indicators have also reached a ceiling, with no real possibility of further improvement.
So we are left with a dilemma: should we remove indicators once certain statistical criteria are met (high achievement, low exception-reporting, little variation between practices and consistently high performance over time) or do we leave them in, knowing that the incentive is essentially paying for more of the same?(9)
My own view is that if the government wants the QOF to be a world-class quality improvement tool, then it needs to remove indicators on a regular basis – but with certain caveats. Evidence from Kaiser Permanente in California suggests that removing financially incentivised indicators may lead to a decline in performance levels.(10)
Part of the reason for working with Kaiser was because there was no equivalent data set for the QOF, although in the US system it’s important to note that payments were far smaller, and at the organisation, not the physician, level. We found four “shared” indicators (yearly assessment of the level of glycaemic control, screening for diabetic retinopathy, control of hypertension and cervical screening) and looked at performance as financial incentives were attached and removed over time.
Across the 35 Kaiser facilities, the removal of incentives was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical screening. This suggests to me that it is safe to remove indicators that have run their course, as long as you realise that care may change in that area. This means we will need a system in place to monitor achievement levels in areas where indicators have been removed, and that we will also need to agree the point at which they should be reintroduced.
Finally, the new government seems to be focusing on outcomes in healthcare. Once again, it’s difficult to argue against this in the generic – it’s far more important from a patient’s perspective to look at morbidity and mortality than at process measures. But in the context of the QOF, I would suggest that the processes in place, such as prescribing evidence-based medications after a heart attack, or the intermediate outcome measures, such as keeping blood sugar levels low, should lead to better “hard” outcomes downstream.
It is also important to remember that indicators need to be within the control of the primary care team, and be constantly mindful of potential unintended consequences of the QOF. For example, if pure outcomes are prioritised and, for instance, smoking cessation rates rather than referral for advice and treatment are introduced, this might have the unintended consequence of fewer GPs wanting to practise in deprived areas where smoking rates are higher and cessation rates lower, exacerbating the inverse care law.(11)
I firmly believe the QOF can be a force for good in improving patient care, but it’s a blunt instrument and needs careful wielding. The “new improved” QOF process should lead to better clinical indicators, but there are hard decisions ahead in terms of its shape and size.
1. Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. N Engl J Med 2007;357: 181-90.
2. Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009;361:368-78.
3. Doran T, Fullwood C, Kontopantelis E, Reeves D. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet 2008;372:728-36.
4. Lester HE. The effect of the Quality and Outcomes Framework on health inequalities. BMJ 2008;337:1181-2.
5. Gillam S. Should the Quality and Outcomes Framework be abolished? BMJ 2010;340:1338-9.
6. Walker S, Mason AR, Claxton K et al. Value for money and the Quality and Outcomes Framework in primary care in the UK NHS. Br J Gen Pract 2010;60:213-20.
7. Mcdonald R, Lester HE, Campbell S. A nice little easy job? Practice nurse identities and the effects of the new GP contract in the English National Health Service. Soc Sci Med 2009;68(7);1206-12.
8. Checkland K, Harrison S, McDonald R, Grant S, Campbell S, Guthrie B. Biomedicine, holism and general medical practice: responses to the 2004 general practitioner contract. Sociol Health Illn 2008;30:788-803.
9. Reeves D, Doran T, Valderas JM et al. How to identify when a performance indicator has run its course. BMJ 2010;340:c1717.
10. Lester HE, Schmittdiel J, Selby J et al. The impact of removing financial incentives from clinical quality indicators. BMJ 2010;340:c1898.
11. Tudor Hart J. The inverse care law. Lancet 1971;297:405-12.
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