QOF – too much of a good thing?

Doran T, Kontopantelis E, Valderas J, Campbell S, Roland M, Salisbury C, & Reeves D (2011). The effect of financial incentives on incentivized and non-incentivized clinical activities. Evidence from the UK’s Quality and Outcomes Framework. British Medical Journal, 342 : 10.1136/bmj.d3590 Access this article.

We know from our research that QOF makes a small difference to quality of care, albeit a fairly small one. But what about conditions that aren’t in QOF. Does their care get better too? This is sometimes called a halo effect. Or maybe it gets worse because GPs are too focused on QOF conditions.

Tim Doran and colleagues from Manchester, Cambridge, Bristol and Oxford (BMJ 2011; 342: d3590) tried to answer this question examining over 600,000 records from GPRD and looking at quality of care for a range incentivised and non –incentivised conditions for three years before and after QOF came in. They looked at the quality scores for these conditions by comparing what actually happened with pre-QOF trends.

The answer is that non-incentivised conditions got worse. Or at least, if they were improving in the pre-QOF period, their final position was lower than it would have been if their pre-QOF trend in quality scores had continued.

Another example of an unintended outcome from QOF was the 48 hour target for appointments to see a GP. This led to booking systems that perversely made it more difficult for patients make appointments, especially with a doctor of their choice.

Does this matter? Yes, it does. You could argue that the most important diseases are in QOF (CHD diabetes etc) so conditions outside QOF don’t matter so much. This is a false argument for two reasons. First, QOF only covers a small part of what GPs see on a day to day basis, and second, QOF indicators provide very patchy coverage of the care required for conditions that are in the QOF (e.g. good for diabetes, poor for depression).

Some would say that this is an inevitable consequence of financial incentives. All powerful incentives carry the risk of unintended consequences. So what’s the solution? Well there isn’t an easy one as no payment systems are without their problems, and it would seem odd to return to the previous system where GPs took home less pay if they staffed their practices to provide a really high standard of care.

I think the answer is to make QOF smaller and responsible for a smaller proportion of practice income. This would reduce the importance of QOF in GPs’ eyes and reduce the risk of unintended consequences. Indicators could rotate but should always support care which is in line with GPs’ professional values. GPs’ pay needs to be a balance of basic allowances, capitation and quality payments. Getting this balance right is something that health care systems in all countries struggle with. No other country has made as much as 25% of doctors’ income dependent on a pay for performance scheme like QOF, and we shouldn’t either. An alternative might be to make QOF bigger and bigger so that it tried to cover all aspects of care, but that would be a serious mistake which would lead to further unintended consequences and gaming.

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