admin
Has the Quality and Outcomes Framework (QOF)—which pays GPs for recording processes and achieving clinical outcomes—led to improvements in patient care? This is the question that Ho and colleagues have tried to answer in their latest synthesis of the evidence.1
The system was introduced in 2004 and initially provided as much as a quarter of general practice income. Over the past 21 years the care indicators that are rewarded have changed, some being withdrawn and new ones introduced. This has provided a rich set of data to help identify whether incentivising specific elements of care will make them more likely to happen—and whether that improvement lasts when you stop paying.
The way we look after patients with long term conditions has changed beyond all recognition since I started in general practice; however, it’s not easy to disentangle which changes are attributable to QOF and which were going to happen anyway. Around the time QOF was introduced, the growing sophistication of our IT systems made it easier to create registers of patients with specific conditions and set up recall systems to organise their care. There was a trend towards more standardised care even before QOF’s introduction, with guidelines about best practice influencing how we monitor and treat patients.
There are caveats when looking at improvements attributed to the introduction of QOF indicators—or at the seeming deterioration in care when a particular indicator is no longer rewarded. Some rises and falls are likely to reflect variations in reporting rather than a change in activity. For instance, GPs talked to their patients about their cancer care before it was an incentivised activity and will continue to do so even though it’s no longer rewarded financially.
There’s also a question about the things GPs can’t do because they’re too busy attending to QOF points. If you fail to reach the targets you lose income, so in many practices there’s a scramble towards the end of the QOF year to summon patients who haven’t attended for their reviews. Clearly, this can lead to a skewing of our attention towards patients who have conditions covered by QOF and away from patients with other illnesses.
QOF also exerts an effect within consultations: at the bottom right corner of my computer screen there’s a little pink box listing all the data or processes missing from this patient’s record. For example, it alerts me if there’s no record of smoking cessation advice being offered or if blood pressure hasn’t been measured in the past year. But we have to be careful to give our full attention to the patient’s agenda—the reason they came to see their GP—before we respond to the “nag box” in the corner.
In more complex reviews (for instance, of dementia or mental health), until this year multiple pieces of information needed to be recorded to claim the QOF points. Many patients may be seen only once a year, and this is a chance to find out what’s going on for them, how they’re coping, what extra help could be useful, or any new symptoms to be investigated. There was a real risk that the appointment would instead be spent focused on the computer screen, asking closed questions and ticking boxes on a template.
This year QOF has been slimmed down considerably, and the emphasis is now on preventing cardiovascular disease. Personally, I’m grateful to have had most of this burden lifted—and we can take heart from this latest research,1 which seems to conclude that it probably won’t make a lot of difference to patient outcomes.
