How the Government is proposing to change GP incentive schemes

The Government has launched a public consultation on the future of GP incentive schemes, which will be used to underpin negotiations for the 2025/26 GP contract. Emma Wilkinson takes a closer look at what’s on the table.

Incentive schemes like the QOF, first introduced in the 2004 contract, and the more recent IIF for PCNs have been important in ‘shaping and driving improvements’, the Government says in the introduction to its public consultation.

On the plus side QOF has helped set and achieve ambitious targets, improve the management of long-term conditions and enhanced patient experience, the document seeking views on its future notes.

But ‘as the healthcare landscape evolves’ incentive schemes may also need to adapt if they are to serve the best interest of patients and respond to changing population needs, the Government says.

Healthcare professionals, patient groups and the wider public are now being asked for input on whether incentive schemes – both QOF and the IIF – should be scrapped entirely or what alternative mechanisms could be used instead to encourage quality of care. The consultation also asks for views on the scope of any future scheme and how to minimise the administrative burden for primary care.

We take a closer look at what has been put forward.

Role of incentive schemes in general practice

It has now been two decades since incentive schemes based on clinical indicators were first introduced into the GP contract. The latest iteration of QOF includes 76 indictors each with specific targets.

The Government believes that incentives are a valuable tool to direct resources towards ‘priority clinical areas’ and lists a range of studies that have shown better quality of care, reduced variation and better patient outcomes as a result of QOF. This includes analysis from the National Diabetes Audit and a study showing benefits for people with serious mental illness.

There was also ‘strong evidence’ from Scotland published earlier this year which found the abolition of the QOF in 2016 led to reductions in recorded quality of care. The researchers concluded that any changes to pay for performance schemes should be ‘carefully designed and implemented’.

But the Government also says it recognises that QOF has limitations ‘and can take focus away from non-incentivised areas of care’. It had already signalled that an overhaul of QOF was on the horizon to become ‘more streamlined and focused’.

The starting question to the whole consultation is whether schemes like the QOF and IIF should form part of general practice income at all.

Stakeholders are also being asked for their views on whether parts of the schemes that incentivise prevention and proactive care ‘can provide a helpful counterbalance to the reactive work of meeting on-the-day patient requests’. Those who disagree are being asked how instead the Government could ensure sufficient resources are used for preventive and proactive care in general practice.

Targets

Since QOF was first introduced, GPs have been given absolute targets they have to meet to achieve the points and therefore income. But such targets can impact on health inequalities, the Government notes. Absolute thresholds are used to assess performance with everyone expected to meet the same targets regardless of factors such as the demographic of their population.

The most stark example of this type of perverse incentive has been in childhood immunisations where uptake can be highly dependent on the practice population. Those in deprived areas have long criticised how much harder they have to work to try and hit uptake targets as well as losing income if they fail. Last year Pulse reported that GP practices would lose thousands in income from immunisations after stricter targets were introduced.

Uptake rates for vaccinations are falling nationally and a new NHS England vaccination strategy seems to signal the end for QOF targets in this area. But it’s not just immunisation with practices in poorer areas managing patients with more complex needs and on average with fewer staff. A report from the Health Foundation in 2021 noted patient deprivation may make it harder to achieve QOF points.

One possibility being consulted on is the option of ‘relative improvement targets’ that instead of being a one-size-fits-all take account of the ‘the varying starting positions and populations of individual practices’. Would this be a better approach to delivering improvements in care quality while also addressing health inequalities, it asks.

In the consultation document, the Government notes that ‘the use of absolute thresholds plays a crucial role in bringing all practices closer to nationally agreed standards, helping to ensure that the NHS is delivering value for money’.

But it adds: ‘If a target is set, say at 85%, and practices achieve this target, it could be argued that the 15% that are missed might be those harder to reach that would have benefitted most from the intervention’.

Respondents are also being asked for thoughts on what other ways incentive schemes could be used to address health inequalities.

Scope of incentive schemes

A key part of the consultation, which is open for 12 weeks until 7 March, is additional areas that should be considered for inclusion within future incentive schemes. The Government is looking for thoughts on the ‘concepts’ the questions introduce rather than specifics and note they ‘recognise that we could not expand the scope without considering the total number of indicators or the funding impacts that would need to balance effort and reward’. 

Their starting point is a belief that incentives should prioritise focus on clinical outcomes, such as rates of heart attacks and strokes, while being aware that ‘that clinical outcomes are rarely solely shaped by the actions of practices or PCNs alone’. For this reason, outcomes-based incentives could be perceived to be ‘unfair’, the consultation says.

‘Other measures can also be effective at boosting desirable activity such as maintaining asthma registries, completing diabetic foot checks or measuring blood pressure, rather than directly rewarding clinical outcomes,’ it adds.

Views are being sought on what type of indicators might work best, whether that is a clinical code that a task has been done such as recording whether someone is currently a smoker, or a clinical activity such as an annual review, clinical outcome like the rate of stroke. Also on the list is the option of quality improvement with the example given of a local project to improve patient experience or staff wellbeing.

And if there is a focus on clinical outcomes one of the challenges to that is deciding what size of population that should be aimed at. ‘We could choose to incentivise change in an outcome that is measured at a PCN level (with an average population of around 50,000 patients) or at ‘place’ level (250,000 and above population),’ the Government says.

But it also notes that as the population level expands individual practices have less influence ‘emphasising the need for collaboration and partnership within the PCN or potentially across a place to achieve shared outcomes’.

Pressures and multimorbidity

The role that general practice can have in reducing unplanned hospital admission as well as A&E attendance has long been debated. Risk stratification, targeting frequent attenders and a greater focus on prevention are also areas that policy makers have pushed in various guises. Back in 2014, there was an unplanned admission direct enhanced service that involved care plans. Later analysis showed it had failed to have an impact on hospital activity.

In the consultation, the Government says ‘we believe general practice can help to reduce pressures on the rest of the health system’, giving the examples of effective management of long-term conditions. It asks whether there is a role for incentive schemes in focusing on helping to reduce pressure on other parts of the system.

‘Any incentive scheme should consider the quality of care for patients with multiple, complex long-term conditions’, the consultation states but at the moment both QOF and the IIF are ‘focused on improving care quality for single conditions’.

In reality patients, who are living longer, often have multiple complex long-term conditions. Frailty is often also part of the mix and ‘more holistic joined-up care planning and delivery’ can be beneficial the consultation notes. This case has already been made by the Government who are developing a major conditions strategy, which will focus on lifestyle drivers and early diagnosis.

With this in mind, should incentive schemes be used to better manage this population of patients, the consultation asks, by being ‘more tailored’ towards boosting quality for multiple long-term conditions.

Access and continuity

Patient access is already a national priority with the primary care recovery plan setting out a ‘Modern General Practice Access’ model. Through the IIF, this year practices were incentivised to offer appointments within two weeks or less and there was also payment for developing local capacity and access improvement plans to be signed off by ICBs.

The consultation notes that despite access being a top priority ‘there are currently no additional payments for practices that excel in providing a positive experience of access for patients’.

It adds: ‘We are particularly interested in your views on whether incorporating indicators for experience of access based on survey data could spur improvement.’

The risk of too much focus on speed of access, is that continuity – proven to be beneficial for patient outcomes and GP wellbeing – gets lost. The Future of General Practice report from the Health and Social Care Select Committee in 2022 concluded that continuity was in decline – in large part as a result of demand outstripping capacity and it called on Government and NHS leaders to make it a priority.

‘Continuity of care is important to both clinical quality and patient experience of care,’ the consultation notes and there could be ‘scope’ for an incentive scheme to encourage it either through survey data or using general practice records to measure it. Respondents are being asked whether or not its inclusion in a future incentive scheme would be a good idea.

The Government adds: ‘However, we also recognise the importance of patient choice and clinical judgement in identifying which patients need or want continuity of care, and respecting that some patients may prioritise speed and convenience of access over seeing a specific professional.’

Locally driven quality?

Some ICBs have said they would like to have more flexibility in being able to use incentives to address local quality issues that affect their populations. For this there are a couple of options under consideration.

The consultation asks whether, for example, ICBs should be able to select local priority indicators from a national menu. Maybe there is a particularly high level of undiagnosed diabetes or poor screening uptake that could be locally targeted. Or the other option suggested is that a certain incentive could be ‘strengthened’ by putting additional local funding against agreed indicators.

Respondents are being asked to what degree should an incentive scheme be local or national and the influence that ICBs should have. Also on the table is whether ICBs should be free ‘to choose their own indicators and put local funding against those indicators’.

Included in the consultation is the question over whether incentive payments are better done through PCN-level schemes rather than at the practice level. ‘We want PCNs to foster peer review of data and continuous quality improvement across practices. One approach could be to link incentive payments to PCN rather than practice achievement,’ the consultation document says.

This portion of the consultation does not mention inequalities but a recent report found that flawed PCN funding streams may have contributed to worsening health inequalities due to imbalanced funding mechanisms.

What else?

Healthcare professionals, patients and other stakeholders are also being asked to give their views on patient choice and whether this should be incentivised and effective prescribing with ‘tackling inappropriate prescribing, problematic polypharmacy, low-carbon prescribing and promoting the use of the most clinically and cost-effective medicines’, given as examples.

And last but not least given it is one of the most common complaints from clinicians about incentive schemes such as QOF is what can be done to minimise the administrative burden on practices.

‘We have heard that QOF and IIF can become ‘tick box exercises’ that distract clinicians from focusing on the needs of their patient and using their clinical judgement,’ the consultation says. Feedback can be provided on how to reduce the bureaucracy including on ‘the number of indicators and the processes associated with delivering the schemes’.