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At the heart of general practice since 1960

Is the new QOF formula just as unfair as the old one?

The demise of the QOF square root formula hardly came as a surprise.

By Richard Hoey

The demise of the QOF square root formula hardly came as a surprise.



It had become a bit of an embarrassment to both the GPC and the Government.

Academics and GPs in deprived areas were queuing up to condemn the payment system as perverse.

Pulse had tried to commission a debate on whether the square root should stay or go, but it took so long to find anyone to put the case for defence that by then its fate was sealed.

So why the controversy now? If the formula was doomed, was there anything the GPC could have done to ease the transition to a new system?

The answer to that is a straightforward Yes – and in more ways than simply by securing a more watertight system of parachute payments from PCTs.

Because while it's true that the demise of the square root formula was fully expected, the method the GPC signed up to for abolishing it was not.

The new formula, based straightforwardly on prevalence, is just as crude as the old one and less fair than some of the possible alternatives.

Let's go back to the original case for the square root formula. Workload is not simply related to the number of patients, so the argument went.

There are registers and call-and-recall systems to set up, nurses to employ and train, clinics to run and paperwork to do. There are then two sets of costs – those specifically related to the number of patients, and those that are constant between practices, or at least between practices of a similar size.

The square root formula was the GPC's stab at taking into account those two costs. And it didn't work, for a number of reasons, but mainly because it greatly underestimated the component of workload that is indeed related to the number of patients on your disease registers.

But there are other ways of taking into account the two sets of cost.

The negotiators could have split the money available for each QOF point, with the majority paid according to the ratio of practice to national average prevalence (as it will be from April) and a small amount paid at a constant rate, or a rate constant to all practices of a particular size.

That might have dampened down the vast swings in funding from one practice to the next, which could leave some down by £100,000 or more. It might have saved a few from going to the wall.

If we're going to think really blue sky, part of the payment per point could even have been related to the number of partners at a practice, as an incentive for the creation of partnerships.

All these solutions would have been immensely, brain-bruisingly complicated of course.

But then who properly understood the square root formula? Not, it is fair to say, the GPC.

By Richard Hoey, deputy editor

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