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QOF ‘has led to reductions in emergency admissions’

The introduction of QOF led to reductions in emergency admissions for conditions that were incentivised in the framework, leading to annual savings of £92.5m, a study in the BMJ has shown.

The study’s authors found that the reductions in emergency admissions were greater than would be expected from improvements in care processes resulting from QOF, but were independent of other changes in the health system during the same period, suggesting QOF had led to overall improvements in care of these conditions beyond the incentivised processes.

It comes at a time that the health secretary and the GPC are looking to reduce the size of the QOF, while NHS England has announced this month that CCGs will be able to ditch the framework without approval.

But lead researcher Professor Martin Roland – who is professor of health services research at the University of Cambridge and a part-time GP in Cambridge, and a leading architect of QOF – said that this was one of the first papers to show an improvement in outcomes, and argued that the QOF should not be reduced.

The researchers looked at emergency admissions for ‘ambulatory care sensitive conditions’ – those that could have been avoided through management of the acute episode in the community or by preventative care – over the five years before and seven years after the introduction of QOF in 2006.

Avoidable emergency admissions for conditions that were included in the QOF fell after the framework was introduced, compared with pre-existing trends, whereas those for other conditions continued rising steadily.

Adjusting for the pre-QOF trends, the avoidable admission rate for incentivised conditions was nearly 3% lower than for the non-incentivised ones within a year of QOF being introduced – and 8% lower by the seventh year.

The researchers estimated the reduction in admissions saved the NHS £92.5 million in 2010/11.

Although the savings appear small relative to the overall cost of the scheme – £1 billion per annum – they noted these were on top of other benefits of QOF, including improved use of clinical computing systems and ‘substantial uplifts in family practitioners’ income to encourage recruitment and retention in the speciality’.

The team concluded: ‘The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised.’

Professor Roland told Pulse the study was one of the first to show an impact of pay for performance on long-term health outcomes, and suggested the benefits went beyond the incentivised areas.

Professor Roland said: ‘There have been lots of papers that have shown financial incentives make some difference to process measures, especially when combined with other quality improvement activities, but very few papers have shown an improvement in outcomes – and this is one of the first to do that, so that’s obviously quite important.’

He added: ‘We know the indicators for blood pressure control and things improved a bit following the introduction of QOF. But they were already improving anyway, there wasn’t a huge change – whereas this is quite a big change in admissions. So it makes you think that other things were either going on independent of QOF – or GPs were doing other things to genuinely improve the care in those patients.

‘We looked at things like the introduction of rapid access to chest pain clinics, but none of those occurred at the same time as the change we saw. So probably this means GPs weren’t just thinking about these QOF indicators but improving a range of aspects of care for these patients with long-term conditions.’

Professor Roland noted that the improvements in the incentivised areas did appear to have occurred at the cost of care in other areas – where trends in emergency admissions remained on the same trajectory throughout – but said there were limits to what further areas could be incentivised to achieve reductions in avoidable emergency admissions for other conditions.

He said: ‘I think [extending QOF] is probably the wrong way of going about it – if you try to say, we’re going to measure everything, well some things are just very difficult to measure.   

‘I think there are a range of ways you can try to maintain and improve quality but they don’t all have to be tied to financial incentives.’

BMJ 2014; available online 11 November

>>>> Clinical Newswire

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