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Report to DH demands crackdown on QOF

By Lilian Anekwe

Exclusive: A major report prepared for the Department of Health has questioned whether the QOF has had real benefits for patients and recommended cracking down on GPs over gaming of exception reporting and ‘fraudulent' practice.

The analysis, by a UK-wide team of primary care academics, found evidence the benefits of QOF targets came at the expense of a decline in quality for the same disease in areas not covered by indicators.

It also uncovered evidence that GPs felt interpersonal care had suffered, and patients felt continuity of care had been disrupted, since introduction of the QOF in 2004.

But the most controversial finding of the analysis, designed to inform the Government's planned overhaul of the QOF, was of evidence of abuse of exception reporting and even fraud. That allegation was immediately dismissed by the GPC, which insisted cases of gaming were extremely rare and that exception reporting was ‘crucial' to protect patients from overtreatment.

Researchers for the Government's National Institute for Health Research combined statistical analysis and interviews with a hundred practising GPs, plus NHS managers.

They uncovered one case, reported by a manager, where a GP fraudulently recorded 48 blood-pressure readings in 30 minutes: ‘One of the worrying findings from our study is the report of data falsification. We do not know the extent of such events, but the fact PCTs may not be monitoring QOF in sufficient detail gives some cause for concern.'

The analysis also found that when QOF thresholds rose from 50% to 60% in 2006/7, exception reporting at practices whose achievement had lain between these values jumped from 15.7% to 25.9% – in apparent evidence of gaming.

Its authors said gaming was unlikely to be widespread, but ‘concerns remain that raise questions about the desirability of continuing with this practice'. They made a series of recommendations to the DH for an overhaul of the current system.

These included:

  • collating all reasons given by GPs for exception reporting on a national database
  • clarifying reasons to exception report, with removal of ‘duplicates' – such as ‘refusal to attend' and ‘informed dissent'
  • asking NICE to conduct a full review of exception-reporting procedures
  • ‘severe penalties' for practices ‘found to abuse the system'.

The report found scores for overall quality – clinical care, access and continuity – were higher ‘for aspects of care linked to incentives than those not'. For asthma, scores for care linked to incentives increased after 2005 but those for care not linked to incentives fell. Continuity of care ‘declined significantly' after the QOF, with patients' evaluations falling by 4.1 percentage points in 2005 and 4.3 in 2007.

Study leader Professor Ruth McDonald, professor of healthcare innovation at the University of Nottingham, concluded the QOF was a ‘blunt instrument' which had led to unintended consequences: ‘To a certain extent GPs are ticking boxes rather than delivering what we'd say is good-quality care.

‘We shouldn't just continue with policies – we need to evaluate the QOF rather than assuming it works.'

GPC negotiator Dr Peter Holden said: ‘Exception reporting is crucial because it protects practices from having a small cohort of people damaging practice profits. The only other option is to underwrite the cost of clinics ourselves.'

The DH said: ‘The QOF did bring some improvement but did not go far enough and we intend to address this.'

Blood pressure monitoring: the report detailed concerns over one GP who recorded 48 readings in 30 minutes Key findings

• Financial incentives contributed to high levels of attainment of quality targets and reduced variation of quality
• Evidence of data falsification and deliberate fraud to reach QOF targets
• The risk ‘that practices may neglect aspects of care due to a focus on meeting QOF targets'
• Quality of unincentivised aspects of care and continuity declined after the QOF
• Raising thresholds from 50% to 60% was linked to a 10-point rise in exception reporting

Source: The impact of incentives on the behaviour and performance of primary care professionals, August 2010

Click here to read the full report