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Professor Martin Roland: 'QOF should be no more than 15% of practice income'

We’ve learned a lot since the launch of the Quality and Outcomes Framework, argues Professor Martin Roland, but now it’s time to start cutting it back

Almost everyone was surprised at the large amount of money attached to QOF when it came in 2004. The reason was fairly simple: GP recruitment in the late 1990s was poor and the Department of Health (DH) had accepted that GPs needed a substantial pay rise.

It was also the time when Tony Blair had announced a big increase in NHS funding, so there was money about. However, the Treasury weren’t going to give GPs something for nothing, and the ‘deal’ was that they’d get a big pay rise in return for improving quality.

The DH, of course underestimated how well GPs would do – unlike GPC who had always told the government that GPs would score highly from the start. However, the large amount of money that came with QOF had a number of perverse effects such as distracting GPs from important aspects of care that weren’t measured.

Past mispayments

Although QOF was controversial at the beginning, there was remarkably little complaint about the actual indicators themselves. They were, by and large, things GPs thought they should be doing anyway. However, later on new indicators began to be introduced which had little professional support. Some of these were spectacular failures, of which two examples bear description.

The first was the use of PHQ-9 for depression using a standardised scale (PHQ-9), the rationale being that GPs underestimate the severity of depression. This indicator was very unpopular from the start, partly because producing a questionnaire half way through a consultation for depression often seemed inappropriate and intrusive. After a few years, the indicator was dropped, to be replaced by a less intrusive but meaningless one about bio-psychosocial assessments. This is now also to be dropped. The message here is that not everything that is important can be measured and you shouldn’t force indicators onto aspects of practice that aren’t easily measured.

A second indicator which went seriously wrong was the attempt to pay GPs on GP patient survey scores about getting appointments. Speedy access has never been high on GPs’ agenda, with doctors more concerned about issues such as continuity of care.

However, the misery was compounded by a misjudgement in the formula linking payments to survey scores which meant that there was large, random, year to year variation in payments, and a practice that had made considerable efforts to improve appointments could find that their payments the next year were reduced.

Future QOF

There was general agreement that QOF needed a major revamp, and it’s had a modest one, both the indicators and the amount of money attached to QOF.

The most important lesson learned is to stick to indicators which have clear professional support, and be careful how you link payment to performance, especially when it comes to surveys.

The overall value of QOF has now been reduced, which is a good thing. It was certainly too dominant in relation to the many ‘non-QOF’ things that GPs have to do. In my view, its value should come down further, until it’s only worth 10-15% of gross practice income. This will remove more of the perverse effects of QOF while still allowing some aspects of good care to be rewarded.

As QOF becomes smaller, it should become more flexible, with indicators and conditions being rotated.  CCGs and LATs are also likely to introduced performance related incentives to meet local needs. Pay for performance isn’t on the way out, but what we have seen this month is a welcome reassessment of its place in general practice.

Professor Martin Roland is professor of health services research at Cambridge University and a part-time GP in Cambridge. He advised the government and BMA negotiating teams on the development of the original QOF from 2001 to 2003.

Readers' comments (4)

  • QOF is a helpful tool. It still needs greater specificity though so that it doesn't produce mass medicalisation of large swathes of the population for natural senescence processes e.g. CKD with all the additional drug prescribing it engenders. Side effects and complications may outweigh any benefits if we're not more discriminating.

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  • Dr Mustapha Tahir

    QOF ensured only one thing, defrauding the NHS & the tax payer whilst ensuring The NHS counter fraud unit, now so called NHS protect, becomes totally ineffective and toothless. Now it's time for those at the top of the profession, with conscience, to bring an end to this tick box and grab money pervasive culture.

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  • QOF has from the beginning been misconcieved.it underrates grossly the complexity of consultations and is totally against patient centred care.in a profession with far too littlle consulting time to offer..it has been very damaging...by all the consulting time it has wasted and the increase in consultation rates and dr dependency.Finally they see their mistake..about time!...it would have been far far far better to have increased standards by clinical governance...increased protected learning time..ie trating gps as professionals who get satisfaction mostly by good work not money(wow a new idea treating us as professionals not as piece work chasing widgets!!)
    QOF has been simple minded dicatatorial demeaning and damaging to patient care.

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  • Grab money ? Our workload and consultation rates have increased 50% and our pay has fallen 20% in 10 years. The result is a 50 % reduction in pay per consultation, at least. In other words, we are doing twice as much work for the same money. If we talk take home pay, as we should, our pay per consultation can be as low as £2.00, and the best might get £ 4.00.

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