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Quality of care ‘decreased’ after QOF abolished in Scotland, suggests study

by Eliza Parr
29 March 2023

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A new study has claimed that the abolition of QOF in Scotland was linked to a reduction in the recorded quality of care, although doctors’ leaders have said the results should be treated with caution. 

Following the abolition of the scheme in 2016, researchers claimed there was a ‘significant reduction’ in performance across several indicators, with the strongest impact on those that required recording by tick box. 

Based on these findings, the authors of the BMJ paper said that continuing to collect data after the removal of pay-for-performance systems is ‘critical’ in order to monitor the impact.

But the BMA urged ‘considerable caution’ when interpreting these findings, saying that the study cannot definitively show that the removal of the scheme had an impact on the actual quality of care, rather than just the recording of it. 

The study, published last Wednesday, used a controlled interrupted time series analysis to determine whether the withdrawal of QOF in Scotland had an impact on recorded quality of care, compared with England where the scheme continued.

The reasearch was conducted over the financial years 2013-14 to 2018-19, with 864 practices in Scotland and 6873 in England in the final year.

It found a ‘significant decrease in performance’ for 10 of the 16 indicators three years after withdrawal of the financial incentives. 

The reduction was largest for recording of mental health care planning and diabetic foot screening, but was also ‘substantial’ for blood pressure and diabetes control indicators. 

While the authors recommended that policymakers continue to collect data after removing any financial incentives, because assuming quality will remain high is ‘problematic’, they also recognised the potential benefits of withdrawing schemes like QOF.

They said: ‘The introduction of incentives was associated with a negative impact on the quality of care for non-incentivised conditions and evaluating quality of care more broadly would be invaluable, not least because the withdrawal of QOF incentives in Scotland was accompanied by the introduction of new approaches to quality improvement and this new approach may have had positive effects on general practitioner satisfaction, recruitment, and retention.’

Dr Patricia Moultrie, deputy chair of the BMA’s Scottish GP Committee, said the study’s focus on reported quality of care means it may not properly reflect a real change in quality, since the methods of recording measurements such as blood pressure have changed since QOF was removed. 

The biggest challenge in delivering quality care is ‘lack of capacity’ and GPs can only provide quality care ‘when they are supported and resourced to do so’, according to Dr Moultrie.

She added: ‘Although this research itself needs to be interpreted with caution I think that GPs and patients would agree that the fundamental requirements of quality general practice, timely access to a GP with sufficient time to spend with patients and preservation of relationship based long term therapeutic care, is under threat.’

Dr Kath Checkland, a GP and professor of health policy and primary care at the University of Manchester, said the study’s findings are ‘complex’ and it is not clear whether they show ‘changes in care recording or changes in care quality’. 

In her analysis of the study for BMJ, Dr Checkland highlighted the potential benefits of removing the QOF, such as a bigger focus on continuity of care, and the increase in satisfaction among GPs with their new contract from 2016 onwards. 

However, she said: ‘The new study does confirm previous work showing that the withdrawal of performance targets can be associated with a reduction in documented performance.

‘This is important because most pay-for-performance schemes are modified over time—as indicators are removed and new ones added. 

‘If performance decreases whenever an indicator is removed, then the longer term value of such schemes may be limited.’

Recently announced changes to the GP contract for 2023/24 included a review of the current QOF system in England so it becomes more ‘streamlined and focused’ and an overhauled model will be launched the following year. 

In 2016, Scottish practices stopped working under the QOF and all the funding was put back into the global sum to support moves towards developing GP clusters. 

A version of this story was first published on our sister title Pulse.