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GP leaders’ concerns over ‘gaming’ in Commissioning Outcomes Framework

Leading GP academics have voiced concerns that CCGs may resort to ‘gaming’ to meet targets set by the new Commissioning Outcomes Framework (COF).

The framework has been developed by the NHS Commissioning Board and NICE, and forms the basis of how the performance of CCGs will be assessed. Its performance will also determine quality premium payments made to GP practices.

During a panel discussion hosted by NICE at the RCGP’s annual conference in Glasgow last week, GP academic experts raised concerns about the ‘unintended consequences’ of tying financial incentives to commissioning targets.

Professor Martin Marshall, professor of healthcare improvement at University College London, and a GP in Lambeth in South London, said CCGs would gain indicators by ‘gaming’, and urged NICE to closely observe the ways in which CCGs will achieve the indicators when developing the COF.

‘Clever people game indicators. It will happen’, he said.

He added: ‘Asking high ranking panels in positions of public accountability is not the best way to get into these channels of activities. Asking frontline clinicians and managers how you would gain these indicators behind closed doors is the best way of getting at it.’

‘What we do know from the QOF is that quantitative gaming in the QOF is not that big, but the impact on the credibility of the system is enormous.’

Dr Colin Hunter, chairman of the NICE QOF advisory committee, and a GP in Aberdeen, said ‘gaming can easily distort the reality.’

The thoughts were echoed by Professor Martin Roland, professor of Health Services Research at the University of Cambridge, who said there would be ‘unintended consequences from the introduction of incentives’.

Nick Baillie, NICE’s associate director, said that the panel’s discussion raised ‘important questions in how the COF is used.’

The GPC has voiced concerns that the list of 44 indicators introduced by NICE are bureaucratic, and measure some outcomes that are outside the control of CCGs.

Mr Baillie admitted there was debate around this topic, but said the indicators were tested against strict criteria including whether outcomes measured were influenced by the actions of CCGs.  

The list of COF indicators, which includes measuring outcomes for mortality for cancer and respiratory disease, and patient experience of GP out-of-hours services, are set to be signed off by the NHS Commissioning Board in December.