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Obsession with gaming is a red herring

The latest academic report into the QOF may offer ministers an opportunity to opt for a slimmed down, more focussed framework.

It's been the subject of more research than DNA. The QOF, that grand experiment in pay-for-performance healthcare, has fascinated academics ever since its launch in 2004. Even the New England Journal of Medicine, a US journal more usually concerned with highly technical aspects of specialist care, has published articles about its impact on UK general practice.

Yet for all this earnest effort, there's still no answer to the basic question – does paying GPs to chase clinical targets makes sense for patients and the health service? Studies have see-sawed back and forth between those that regard the QOF as a life-saver, and those who see it as an exercise in bureaucracy and top-down control.

The latest effort to judge the QOF comes in a major report produced for the Department of Health on the use of incentives across the NHS. Its findings are not entirely complimentary. It concludes incentives in the 2004 contract have improved consistency of care but may not have offered value for money, with evidence that improvements in areas covered by QOF indicators are balanced by decline in areas that are not. The report also warns it has uncovered evidence that exception reporting is at times being abused, and at least one example of straightforward fraud.

Its answer is a straightforward, old-school crackdown, with recommendations that inspections should be toughened up, exception-reporting criteria tightened and ‘severe' penalties imposed on those found to have gamed the system.

True fraud, on the rare occasions it is detected, should be punished heavily. The authors describe one case where, according to a PCT, a GP had recorded 48 blood-pressure readings in half an hour. In another, described by a QOF inspector in a letter to Pulse last week, a GP was inputting contrived data en masse outside of surgery hours. Those cases will disappoint most GPs, but perhaps not entirely surprise them – every profession has its odd bad apple.

More worrying is the report's recommendation of sweeping changes to the exception-reporting system. This is a topic a band of academics and DH officials – including new commissioning tsar Dame Barbara Hakin – have never been able to let go, despite repeated evidence that exception-reporting rates remain generally low and justifiable. Of course, a tougher system of checks might unearth the odd case where the rules had been bent. But what about the new layer of bureaucracy that would require, and the ill will it would cause among GPs?

The DH would do better to focus on some of the other findings in this weighty document – particularly that the QOF has disrupted some interpersonal aspects of care. GPs spend far too much time staring at computer screens and not enough looking into their patients' eyes, and personal care could suffer further if practices were chasing new commissioning targets too.

Ministers must choose their priorities, and slim down the QOF to target only those areas of care where it can make a real difference. Not every box is worth ticking.

Pulse editorial