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QOF has failed to have impact on UK population’s health, study concludes

The QOF has not led to reductions in premature deaths in the UK population, according to research that showed there was no link between practices’ performance on clinical domains of QOF and local mortality figures.

The study analysed the relationship between QOF scores at 8,647 practices in England in 2011-12 with mortality data for 32,482 local neighbourhoods made up of around 1,500 people.

Deaths from any cause and those related to specific conditions included in QOF – such as diabetes, hypertension and heart failure – declined over the period three to eight years after QOF was introduced, from 2007 to 2012, but the researchers found no evidence of a link between practices’ QOF achievement on clinical domains and either all-cause or cause-specific mortality rates within practice localities.

By contrast, the team found that mortality was influenced strongly by deprivation, as well as being linked to rurality and the proportion of non-White people in the population.

The study’s authors, led by Dr Evangelos Kontopantelis, a senior research fellow at the Centre for Primary Care at Manchester University, reported: ‘We found that overall quality of care provided by practices – as measured by achievement across all clinical QOF indicators – was not associated with mortality rates in their localities for conditions covered by the QOF.

‘There remained no association when potential effects were lagged for up to three years.’

The team concluded: ‘Higher reported achievements of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.’

They did add, however, that is was ‘possible’ that ‘longer term mortality reductions will ultimately accrue’.

BMJ 2015; available online 3 March

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Readers' comments (12)

  • Bob Hodges

    "They did add, however, that is was ‘possible’ that ‘longer term mortality reductions will ultimately accrue’"

    Timescales indeed.

    We're still waiting for 'outcomes data' based on mortality for treating glycaemia in diabetes, so how are we going to pick this out of the noise in the data for QoF I don't know.

    The other thing that is left unanswered is:

    Without QoF - would mortality rates have been WORSE?

    That's NOT the same as seeing no improvement WITH QoF.

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  • Argil

    The assumption that QOF are/were going to have (positive) impact on the population's health requires for us to postulate that GPs were not looking after their patient's according to basic general practice healthcare principles -because of whatever reason.

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  • Azeem Majeed

    In this kind of ecological study of QOF and health outcomes, factors such as deprivation and disease prevalence tend to have by far the largest impact. QOF itself has relatively little impact. This is partly because most practices are performing well in QOF and there are only small differences in performance between practices. For example, there would be little difference in the impact of QOF on health outcomes in two practices that are performing at 94% and 96% QOF achievement respectively.

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  • Vinci Ho

    QOF was relatively more evidence based when it was first introduced but has been 'contaminated' and manupilated by politicians and bureaucrats in recent years.
    Read the Discussion of the study , found this comment:
    It might be the case that the indicators of the scheme need to be reconsidered and better aligned with existing evidence. For example, clinical trial findings indicate that intensive glucose control is associated with increased mortality,especially risk of cardiovascular death in younger patients,while observational studies have generally demonstrated U-shaped relationships between levels of HbA1c in diabetic patients and death.(53 ,54 ,55 )Similar U-shaped relationships have been observed for other biometric measurements, including blood pressure and total cholesterol levels.55 56 These non-linear patterns might suggest that target values (such as ≤7.5 mm Hg for HbA1c in 2011-12) are suboptimal measures of high quality of care and that target ranges might be more suitable.

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  • 1) There was a trend towards improved outcomes for any cause over time prior to QOF. As far as can be determined there has not been an alteration in this trend following the introduction of QOF, thus QOF cannot be concluded to have provided increased benefits
    2) Studies have also shown that despite secondary care being better than primary care at achieving specified goals (BP, HbA1c, etc), primary care produces better long-term outcomes. This appears to be because primary care tends to be more holistic and "compromises" certain goals to achieve a better overall result - and the evidence supports this
    3) QOF has focused the attention to meeting the goals (because of financial reward) and away from the provider-patient relationship. This has had a terribly negative effect on the provider-patient relationship. This can be readily witnessed in the trend of reporting in the Daily Wail and in the dissatisfaction for both providers and for patients.
    4) QOF is intimately linked with the biomedical model of care. It has taken guidelines and made them "best care" parameters. This runs contrary to the biopsychosocial model that is the cornerstone of effective primary care.
    Ultimately QOF is an abomination that has been inflicted on primary care and the community alike. It has failed to deliver as many predicted it would fail to deliver. Redefining the parameters and fiddling with the widgets is not going to fix QOF and is not going to fix Primary Care, restoring the provider-patient relationship will.

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  • Samuel Lewis

    Strictly speaking, this study failed to find a statistically significant difference in mortality between practices with marginally differences in QoF scores.

    Quelle surprise ! !

    As others have said in other ways, CVD mortality and morbidity is falling dramatically, largely due to preventive measures such as cholesterol, BP, smoking and other risk factor improvements. Should we stop doing it ? Or just rename it as 'core practice' and not get paid ??

    It reminds me of 1990, when childhood 90% vaccination came in. Since we were already vaccinating all the kids who sat still long enough, a local study showed that 'vaccination targets' had no significant effect !!

    hey-ho. I fear this adds to the pressure for us to work even harder , and forgo any QoF cash.

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  • Harry Longman

    Some nicely nuanced discussions but let's face the main sense of the study:
    One gazillion tick boxes later, QOF has failed to deliver the planned/expected/hoped for improvements in public health. So, will we now drop it and spend our resources on what works, without the bureaucracy?

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  • Hazel Drury

    Yet another study to confirm ursarial woodland defecation.

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  • Financial incentives should be given directly to the deprived in order to help them manage their health conditions, not to doctors (who can't in any way be described as financially deprived) for ticking boxes.

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  • What a waste of time , effort and money
    QOF , if anything distracts from good clinical care by focussing on box ticking and monitoring . Chasing points, or you will be labelled as having "low QOF results", at the expense of talking TO the patients and tailoring care to their individual problems,issues and life

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