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Been there, done that

Our blogger, Dr Peter Weaving, discovers QOF in the US - but has it improved care?

GPs in England are totting up their QoF points and prizes and looking over their neighbours' shoulders to see how they performed. As one financial year grinds to a close and another uncertainly rolls out before us my thoughts turn for a final look to the US and the comparisons there.

I thought when we invented performance pay for docs related to clinical outcomes we were cutting edge and the first in the world. Imagine my disbelief when an American CEO, Steve McDermott, commented: 'Yeah, we did that but you didn't follow my advice.'

The year before we implemented our Quality and Outcomes framework an organisation called The Integrated Healthcare Association started the Pay for Performance programme, or P4P. This now covers over 11 million patients in California - a third of the population – but only accounts for two per cent of a physician's income. In case you'd forgotten QoF is nearly a third of yours.

What does P4P cover? 68 measures in five domains: Clinical, Patient Experience, IT, Organisational and now 'Resource Use'. This sounds very comfortable and familiar doesn't it? There's no exception reporting though.

Does it work? Well, initially it produced big improvements in reported patient experience but disappointing improvements in patient care. It worked best in driving physicians to embrace IT and an electronic record which was sorely needed. To quote Steve: 'Looking back it seems obvious, but there was unequal attention to measurement and payment. While the total amount of incentive dollars paid seemed high, they were insufficient to generate breakthrough improvement.'

So…when I look at our incentive dollars set at 30% of income and exception reporting rates of up to two thirds of patients being declared ineligible for a clinical measure can I believe that QoF has produced breakthrough improvement in anything other than our ability to cook the books?