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Health policy experts support QOF cut-back

Health policy researchers have called for a cut-back in work covered by the QOF, after their analysis of the latest evidence showed clear ‘limitations’ in the capacity of the framework to change health outcomes. 

In their review of evidence published in the Journal of Public Health, the researchers argued that QOF has failed to achieve sustainable improvements in health outcomes because of its focus on process-based indicators and the capping of achievement thresholds.

It also found that there had been a decline in the quality of care in some areas that are not incentivised. They called for more research into the impact of QOF on health outcomes as well as further, alternative mechanisms outside QOF to incentivise good practice.

The call comes after NHS England said it wanted to reduce the size of the QOF, to free up resources for alternative ways to incentivise quality care. GP leaders, including GPC chair Dr Chaand Nagpaul, have called for the removal of certain controversial indicators, including the recently introduced indicator on physical activity in hypertension.

The researchers, from the London School of Hygiene and Tropical Medicine and University of Kent, reviewed published studies looking at the effect of QOF on outcomes, focusing on those clinical indicators that measure changes in health status, such as the achievement of blood pressure and cholesterol targets.

From a total of 11 eligible studies, they found the quality of care initially improved for some of these measures after the QOF was introduced, but these soon plateaued thereafter. Meanwhile quality scores for some aspects of care that were not incentivised actually began to decline after a year of the QOF.

The authors suggested this is because QOF’s financial incentives ‘may not be sufficiently challenging’. They argued thresholds of between 50% and 90% were too easily achievable, while indicator targets were suboptimal relative to national clinical guidelines, with blood pressure targets of 150/90 mmHg where guidelines recommend 140/90 or 140/85 mmHg, and COPD indicators too focused on assessing the quantity rather than quality of spirometry.

But the review predates the Government’s recently imposed hike in threshold ceilings in the 2013/2014 GP contract, set at the upper quartile of practices’ performance. That change led to an outcry, with even the head of NICE’s QOF advisory board warning it could disincentivise good care in some practices, as did the introduction of a tighter blood pressure target for hypertension patients.

The authors concluded: ‘The evidence demonstrates that the QOF initially improved blood pressure, cholesterol and HbA1c for diabetes, and the limited impact it has had on other conditions relative to the pre-QOF trend which existed.

‘It also reveals the unintended consequences, which may occur including the non-incentivised clinical activities and the impact on subpopulation groups, which may partly be due to the population exclusions permitted.’

They added: ‘It highlights the QOF’s limitations in improving health outcomes, due to the indicators’ ceiling thresholds and the suboptimal clinical targets when compared with the national clinical guidelines, suggesting that the QOF’s financial incentives may not be sufficiently challenging in some areas.’

Co-author Professor Stephen Peckham, professor of health policy research at University of Kent, said that while tighter targets and raised thresholds had been a feature of the new GP contract this year, he was convinced that there were limits to what it could achieve.

He told Pulse: ‘There has to be a balance – so although a lot of practices are achieving thresholds quite easily, pushing it beyond that is quite difficult.’

‘It drives a very individualistic, single-disease approach at a time when GPs are increasingly dealing with patients with multiple conditions. You could argue that the way that QOF is structured it isn’t very good at addressing those problems,’ he added.

Professor Peckham said more sophisticated measures of overall good management are needed, over longer time scales.

‘These things are more difficult to bring into QOF and they may not work on a simple points-based system – they may need closer management with lump sums given to practices directed at longer-term outcomes. They might well be better done through things like the previous local enhanced services elements of the contract.’

Professor Martin Roland, professor of health services research at Cambridge University and a part-time GP in Cambridge, who advised the Government and BMA on the QOF when it was first introduced, agreed with the conclusions, saying that QOF should be smaller and stick with areas that GPs have control over.

He said: ‘QOF should stick to areas where there is clear evidence measures are linked to outcomes, and then GPs will at least have the incentive to invest in their practice to do those things.

‘There are already indicators around reviewing our patterns of hospital referral – it’s not a very big step that NHS England or CCGs might wish to restrict referrals or hospital admissions, and they could do that by imposing limits and giving people bonuses for staying within those limits or penalties if they went above them. I think those could be potentially quite damaging for patients.’

An NHS England spokesman said: ‘NHS Employers and NHS England are exploring how NICE might provide further analysis to inform discussions with the GPC on changes to the QOF for 2014/15.  It would be inappropriate for us to comment on the detail of these discussions.’