Future proofing the Quality and Outcomes FrameworkBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1942 (Published 25 March 2013) Cite this as: BMJ 2013;346:f1942
As the Quality and Outcomes Framework (QOF) approaches its 10th birthday, radical changes in its content and construction see a parting of the ways between the countries within the United Kingdom. The National Institute for Health and Clinical Excellence and the Department of Health have proposed such changes as dropping the organisational domain; creating a public health domain; raising payment thresholds; introducing directed enhanced services for dementia case finding; ensuring access to online general practice services and telehealth; and case managing patients at risk of hospital admission.1
Concerns about these proposals mean they have not been universally accepted across the UK’s four countries,2 which has led to the first sizeable split since the framework’s inception in 2004.3 Scotland and Wales have departed from England by not introducing all proposed changes to indicators (including the directed enhanced services), allocation of points across domains, and payment thresholds. Practices in England face tougher achievement thresholds and risk losing a sizable proportion of QOF funding if they opt out of directed enhanced services.
In a linked Analysis article (doi:10.1136/bmj.f659), Gillam and Steel wonder about where we are going to next with QOF?4 Whether the framework has had a positive impact is unclear. It has modestly improved the quality of care for chronic conditions, improved systems for providing care, and reduced inequalities.5 However, the framework contributes to polypharmacy and has arguably made care more technocratic and less patient centred. Furthermore, non-incentivised aspects of care have not improved much, and evidence on health gain and cost effectiveness is mixed. It does not provide a ringing endorsement of the framework, and—given the £1bn (€1.17bn; $1.5bn) opportunity costs of the scheme—unsurprisingly the government wants to extract more “bangs” for its “buck.” But are the current proposals for the evolution of the framework appropriate?
The wider context is relevant to this debate. Growing demand for healthcare and unprecedented financial pressures make it imperative that the NHS adapts its ways of working to contain demand and deliver more for less without compromising quality. It seems clear that the Department of Health’s view is that primary care has to share the pain and deliver more.
Government priorities for the reorganised English NHS, outlined in the Outcomes Frameworks for the NHS, public health, and social care, include reducing avoidable hospital admissions and premature mortality; for this second outcome, the UK has again recently been shown to compare unfavourably with other countries.6 Clinical commissioning groups have a statutory duty to improve the quality of primary care and reduce inequalities, and they are accountable to the NHS Commissioning Board for improving these outcomes, which depend in part on the contribution of primary care. Under a government mandate, the NHS is charged with achieving demonstrable improvements in health. Irrespective of any changes to QOF, general practice will be under pressure to tackle prevention, early intervention, and management of chronic disease and disability.
The direction of travel for prevention in general practice is clear from the decision to transfer 15% of QOF points to the public health domain and engage Public Health England in deciding future QOF priorities. GPs may be required to “make every contact count” under proposed changes to the NHS constitution. This chimes with the Royal College of Physicians’ recommendation that GPs be incentivised to manage obesity more effectively.
Almost a quarter of people registered with a GP practice have two or more concurrent chronic diseases, and the absolute number of people with multimorbidities is higher in those under, rather than over, 65 years.7 Because QOF is primarily single disease specific, it does not deal with the needs of patients with multimorbidity and can lead to inappropriate and inefficient treatment.8 Yet general practice will increasingly be expected to work with clinical commissioning groups and local agencies to improve chronic disease management, reduce use of secondary care, and coordinate care across interfaces.
What should the future role of QOF be? Should it be a mechanism for incentivising the practice of evidence based medicine in a few key areas, or should it also be a mechanism for steering general practice to help deliver the wider goals of health policy? Inevitably there will be some overlap between these goals. General practice must evolve and play its part in tackling the epidemiological and financial challenges of modern times.9 Unsurprisingly, QOF is seen as a lever given its cost, but it may not be the ideal mechanism for delivering some of the systemic changes that are needed, including those that require working beyond practice boundaries.
There are undoubtedly risks in making the framework an all purpose hybrid that dilutes evidence based practice to accommodate wider managerial goals. In this case, we need to consider redirecting QOF funds to other ways of supporting developments in general practice.4 The Department of Health also needs to ensure that the different performance assessment (including revalidation), management, quality improvement, payment, and incentive frameworks for general practice are aligned and complement each other. QOF is but one element—albeit a crucial one—in a wider landscape.
The UK’s model of general practice is acclaimed internationally for providing universal, free access to community based healthcare and care coordination, with high levels of patient satisfaction. Over the past decade, QOF has helped drive it in an evidence based direction. Many other countries are also reorienting their primary healthcare systems to deal with the challenges of multimorbidity and cost containment, including through new delivery models, although approaches vary.10 11
Financial incentives for quality improvement in primary care are used in Australia (including the Indigenous Health Incentive for Aboriginal patients) and some European countries, although none matches the scale of QOF.12 13 Some systems also offer incentives for coordinating care. Other payment models are also emerging, such as the “patient centred medical home” in the United States, which rewards practices that meet criteria associated with access, outcomes, and care coordination. In contrast, Israel’s strong primary care sector is supported by a robust QOF-like quality monitoring and feedback system that is not incentivised, but which has enabled the four national health plans to improve quality and health outcomes, and to reduce use of secondary care services.14
As the NHS reorganisation takes effect, giving GPs centre stage as commissioners, it is timely to consider how QOF, along with other levers, can be redesigned to support general practice in improving population health, health outcomes, and care and coordination for people with multimorbidities.
Cite this as: BMJ 2013;346:f1942
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.
This article reflects the opinion of the authors alone, not those of the OECD or its member countries.