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NICE advisers call for QOF shake-up as framework too focussed on areas of ‘relatively low benefit to health’

NICE advisers have recommended a radical change to the way QOF is drawn up, with incentives paid to GP practices under the scheme determined by the magnitude of the expected ‘health gain'.

The researchers said the incentives in the framework were too focussed on areas that had a high workload for GPs, but resulted in a ‘relatively low benefit to health'.

They found a wide variation in the health benefits that could be attributed to clinical indicators in the QOF, and recommend the removal of badly performing indicators, and the revision of thresholds to ensure payments under the framework are evidence-based.

The UK researchers included both current and past members of the QOF Indicator Advisory Committee at NICE, and honorary secretary of the RCGP, Professor Amanda Howe.

Their study – published in BMC Health Services Research - looked at the clinical indicators in the QOF from 2004 and 2006 and found 28 had evidence of lives saved or Quality-Adjusted Life Years (QALYs) gained, which accounted for only 41% of the total QOF payments for the average practice.

Indicators such as those for flu vaccination in patients with diabetes and cardiovascular disease had a relatively high health gain, with a maximum of over 4 lives saved per year in the average practice.

But other indicators had a relatively low health gain, with an indicator for prescribing ACE inhibitors or angiotensin receptor blockers in patients with diabetes and proteinuria resulting in a maximum of 0.2 lives saved over a year in the average GP practice, and relatively little QALY gain per year.

When examining the incentives GP practices gained for a 1% increase in QOF performance, researchers found no association between the payments made and the scale of the improvement.

Study leader Dr Robert Fleetcroft, clinical lecturer in general practice and former NICE adviser, concluded there needed to be a systematic review of all the indicators included in QOF and the thresholds used for payment.

He said: ‘Although the incentives were intended to reward general practice for both the volume and quality of the work done, our findings suggest that the incentives are not aligned with maximising health outcomes, which is an explicit aim of the Department of Health.'

‘The lack of an association between the size of the incentive and the expected health gain may risk skewing activity towards areas with high workload but relatively low benefit to health.'

A spokesperson for NICE said the study looked at indicators introduced before the institute took over responsibility for the framework, but said they would consider its conclusions.

The spokesperson said: ‘The QALY may be one way of assessing outcomes in this context, but it is not the only one.'

‘NICE is responsible for reviewing QOF indicators and the Committee does keep itself up to date on new and emerging research of this kind.'

Dr Ismat Nasiruddin, a GP in Balham, south London, said the study demonstrated that QOF indicators were poorly thought through, and had too little grassroots GP input.

She said: ‘It reduces key issues to tick box exercises and therefore it's not surprising that real improvements in healthcare aren't seen.

‘Good practices do enormous amounts of work in both these areas, and instead of looking at what and how they do it, a ridiculous arbitrary indicators are set which have no bearing on good practice.'



High health gain (>4 lives saved per year in the average practice)

DM18. The percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March

CHD12. The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 September to 31 March


Low health gain (<1 life saved)

CHD6. The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the preceding 15 months) is 150/90 or less

DM15. The percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists)