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It is misleading to conclude the QOF has not improved the population’s health

Trying to link marginal differences in QOF performance with reductions in mortality is missing the point, argues Dr Kambiz Boomla

The conclusions drawn from this paper are misleading. It is looking at differences in QOF scores between different small areas throughout the country, and failing to find a correlation between these differences and falls in mortality rates. 

What is not made clear is that overall the QOF, since it was introduced, not simply in the last few years, has been responsible for considerable change in the ascertainment of high blood pressure, people with heart disease not on cholesterol lowering treatments etc and resulted in the application of uniform standards of care across the country in the management of these long term conditions.  This has resulted in massive improvements. 

The fact is that the differences between well performing practices and badly performing practices are now minor.  Put slightly simplistically, more or less all practices do very well, and this has resulted in an improvement in care.  We have narrowed the gap between the best and the worst, and there are other papers which show this.  Therefore, given the gap is now so narrow between the best and the worst, trying to look at differences in outcomes between the best and the worst to provide a justification of the money spent on the QOF is the wrong approach.  It was never going to find much. 

The correct conclusion to have made is that the QOF has helped to partially overcome health inequalities, and has contributed to the fall particularly in cardiovascular mortality alongside changes in population risk factors, so is money well spent. That we now cannot find any significant differences between good and poor QOF performers is because we are all getting more or less all our QOF points.

Dr Kambiz Boomla is a GP in Tower Hamlets and a senior lecturer in primary care at Queen Mary University London

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Readers' comments (4)

  • With respect, you cannot ignore the evidence. For many, many years prior to the introduction of QOF there was an observed trend towards improved outcomes and increasing survival. There has been no deviation from this trend - certainly not any acceleration in the trend. What you have offered is a subjective opinion to defend what you do and to give it some apparent value. The available evidence has clearly revealed it has made no difference. In the end this is all that counts. Then when you consider just what this exercise in futility has cost you would have to conclude that the net effect has been negative. There has been no evidence it has overcome health inequalities either. The only things QOF has accomplished is providing more useless information for bureaucrats to pour over (and hence the need for more bureaucrats) and to provide politicians a stick to beat General Practice with - both if you succeed and if you fail. Banging your head against a wall will not change your mind, it will only give you a headache.

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  • Dr Boomia, the onus is now on you to prove beyond all doubt that all the hardships to the profession caused by QOF have been worthwhile in terms of clinical advantage.

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  • Samuel Lewis

    The paper on QOF is quite incapable of showing that we have gained or lost in terms of outcomes, since it compares high-acheivers, with very-nearly-high acheivers, and has no control group of gPs not doing QoF.

    Meantime there has been relentless dramatic improvement in health outcomes across the board, less so in deprived areas, but significant nonetheless. 40% less heart attacks, for example.

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  • Samuel Lewis

    A propos "observed trend towards improved outcomes and increasing survival. There has been no deviation from this trend - certainly not any acceleration in the trend. "

    The trend is one of continuous improvement, at different rates in different ages, now decelerating. To my mind, a falling trend must mean an increasing cause - a kind of 'dose-response' curve. One-off causes should produce a step change in rates, not a continuous decline over 40 years.

    There is also the 'ceiling' effect, whereby nearly all practices have QOFed their patients BPs and cholesterols to the max, and so 'achievement' now plateaus ( correlating with decelerating outcome improvements ).
    McShane and Mitchell have argued that this means QoF has done all it can , and should be scrapped...

    oh dear - either we GPs will continue all these benefits without pay 'incentives', or we stop our QOF efforts and watch outcomes get steadily worse. A GP just cannot win , can he ? At least 'anonymous' will get the evidence he seeks, via this sequential controlled trial. It isn't ethical to deny patients evidence-based healthcare.

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