The Quality and Outcomes Framework—where next?BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f659 (Published 07 February 2013) Cite this as: BMJ 2013;346:f659
All rapid responses
In their thoughtful reflection on the value of the quality and outcomes framework (QOF) Stephen Gillam and Nicholas Steel imply that it has contributed to rising prescription rates for antidepressants , and Des Spence also suggests this in his column . I question what if any evidence they have for such a suggestion. Prescriptions for antidepressants have been rising year on year since the introduction of the selective serotonin reuptake inhibitors in 1990, in several countries which collect routine data on prescriptions , only one of which has a QOF.
We found increases in antidepressant prescribing in general practices in the GP research database over the 13 years from 1993 to 2005 to be due to relatively small increases in the proportion of sufferers being put on long-term treatment over time, rather than to a rise in the incidence of diagnoses of depression, which actually started to fall from 2000 onwards . What data we have show that rates of consulting for depression in the UK continued to fall through the period following the introduction of the QOF indicators for depression [3,4], up until the economic crash in 2008, after which they have risen, at least in Scotland . Changes in consulting rates do not seem to relate to the QOF in any obvious way.
The introduction of the QOF depression indicator incentivising the use of validated symptom questionnaires at diagnosis was aimed at improving GPs’ assessment of the severity of depressive symptoms, which is not very accurate when based on clinical impression alone on a single occasion, and can lead to poor targeting of treatment to those who really need it [5, 6]. I know that because I chaired the expert group that recommended its introduction. GPs are prone to putting people on antidepressants too quickly, at the initial presentation, and the QOF indicators incentivising questionnaire use at assessment and follow-up were actually aimed at encouraging more reflection by practitioners before diagnosing depression and prescribing antidepressants. However, under-diagnosis is also an issue as well as over-diagnosis. Kessler and colleagues’ longitudinal study in UK general practice found that, while many patients with depression who were not diagnosed at a single consultation were diagnosed at subsequent consultations, or recovered without a diagnosis, 14% of patients with depression still had a clinically severe condition three years later, had not received a diagnosis, and might have benefited from treatment , so we cannot be complacent about the accuracy of the recognition of treatable depression in primary care. A recent meta-analysis suggests that diagnosis can be improved by the re-assessment of individuals who might have depression .
Gillam and Steel point out that the ‘QOF requirement to monitor people with depression using the PHQ-9’ (which is not actually a requirement but an incentive, and doesn’t insist on the use of that particular questionnaire) has been reviewed with regard to the evidence for its benefit, and because it did not promote a holistic approach to assessing severity of depression. This is true but not a very complete description. Some evidence was found of benefit from monitoring, as has been found in specialist psychological and psychiatric practice , but it was judged to be insufficient to continue to incentivise the use of questionnaires, and further research is needed. In relation to failing to promote a holistic assessment, it should be pointed out that the QOF guidance on the depression indicators always stressed that it was important for clinicians to consider family and previous history as well as the degree of associated disability and patient preference in making an assessment of the need for treatment, rather than relying completely on a single symptom count . Now that the revised QOF guidance on assessment lists a set of bio-psychosocial assessment areas recommended at diagnosis, including the (optional) use of symptom questionnaires , it will be interesting to see how many practitioners continue to use them because they find them valuable, or because they consider that their patients value them .
For the reasons given above, I think it unlikely that killing the QOF would reverse the trend towards prescribing more drugs in general practice, at least for depression. Isn’t polypharmacy the result of a medical response to the increasing multimorbidity found among an increasingly aged population, rather than something we can blame on the QOF?
1.Gillam S, Steel N. QOF points: valuable to whom? BMJ 2013; 346: f659.
2. Spence D. Kill the QOF. BMJ 2013; 346: f1498.
3. Moore M, Yuen HM, Dunn N, Mullee MA, Maskell J, Kendrick T. Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database. BMJ 2009; 339; b3999 doi:10.1136/bmj.b3999.
4. NHS National Services Scotland, Information Services Division. Practice Team Information statistics: patients in Scotland consulting a GP or Practice Nurse at least once for depression in the financial years 2003-2012. http://www.isdscotland.org/Health-Topics/General-Practice/PTI-Statistics... (accessed 16th April 2013).
5. Kendrick T, Stevens L, Bryant A, Goddard J, Stevens A, Raftery J and Thompson C. Hampshire Depression Project: changes in the process of care and cost consequences. British Journal of General Practice 2001; 51:911-913.
6. Kendrick T, King F, Albertella L, Smith PWF. GP treatment decisions for patients with depression: an observational study. British Journal of General Practice 2005; 55: 280-286.
7. Kessler D, Bennewith O, Lewis G, Sharp D. Detection of depression and anxiety in primary care: follow-up study. British Medical Journal 2002; 325: 1016-1017.
8. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009; 374: 609-619.
9. Knaup C, Koesters M, Schoefer D,et al. Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis. Br J Psychiatry 2009; 195(1): 15–22.
10. BMA and NHS Employers. Revisions to the GMS Contract 2006/07. NHS Employers 2006. http://www.nhsemployers.org/SiteCollectionDocuments/Revisions_to_the_GMS... (accessed 16th April 2013).
11. NHS Commissioning Board, BMA, and NHS Employers. Quality and Outcome Framework guidance for GMS Contract 2013/14. NHS Employers, 2013. http://bma.org.uk/practical-support-at-work/contracts/independent-contra... (accessed 16th April 2013).
12. Dowrick C, Leydon GM, McBride A, Howe A, Burgess H, Clarke P, Maisey S, Kendrick T. Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study. BMJ 2009; 338: b663. doi: 10.1136/bmj.b663.
Competing interests: Sessional GP and (unpaid) member of the QOF Advisory Committee for NICE. Former chair of the QOF expert advisory group on mental health responsible for recommending the QOF depression indicators .
Gillam & Steele make a very balanced and reasoned appraisal of the benefits realised, and potential adverse impacts on processes and quality of primary care for the designated long term conditions included in the Quality and Outcomes Framework (QoF).
The summary section on ‘Making Progress’ conveyed the principal issues, and the fact that there are undoubtedly advantages and disadvantages of QoF as implemented, and needs for further development and appraisal (1).
The authors summarise data about general improvements in chronic disease management, and highlight the critical question about whether or not QoF implementation accelerated this improvement trajectory.
In this respect it is important to remember what the ‘state of play’ was regarding chronic disease management in UK primary care before the introduction of QoF 10 years ago. In our qualitative study of 14 general practices in Gwent, South Wales, we noted that in 2004 all practices operated a ‘diabetes clinic’, and half operated an ‘asthma clinic’, but there was no other evidence of structured chronic disease management at all for the range of originally 10, then 17 and now more
Long term conditions included in QoF (2). Several conditions such as inter alia epilepsy, stroke, chronic obstructive pulmonary disease, atrial fibrillation, depression had no formalised ongoing care arrangements. Individual patients may have had safe, effective care, but there were no systematic methods of ensuring that this was provided for the majority of affected patients. Discussions about the value of QoF itself, interpretations of apparent effects (or not) on quality of care (processes), and whether or not to scale back the proportion of GP income realised by achievement in this pay-for-performance scheme (3) should not lose sight of ‘usual practice’ prior to implementation in 2004.
1. Gillam S, Steel N. QOF points: valuable to whom? British Medical Journal 2013;346:f659
2. Edwards A, Langley A. Understanding how general practices addressed the Quality and Outcomes Framework of the 2003 General Medical Services contract in the UK: a qualitative study of the effects on quality and team working of different approaches used. Quality in Primary Care 2007;15:265–75
3. Raleigh V, Klazinga N. Future proofing the Quality and Outcomes Framework. British Medical Journal 2013;346:f1942
Competing interests: No competing interests
The future of QOF is an important matter but it is the tip of a massive iceberg that General Practices face in the future. Changes to QOF generally bring further work for the same resource. Work overload and lack of resources to cope with this increasing work are more general problems. To give some examples the prevalence of diabetes has risen by about 50% in recent years. Patients with this condition are living longer and require more intensive treatment regimes and monitoring. There are no funds to provide this care. Many chronic diseases are the same - a symptom of an ageing population.
Patient expectation, the number of problems brought to a single consultation and patient annual consultation rates continue to rise. These bring huge manpower and cost implications.
Practices can't cope with their current resource. The future of General Practice, the cornerstone of our NHS, will die unless there is a serious re-think on how to fund practices more appropriately for the actual work that they do. Politicians won't fund practices directly as they have no means to regulate the funding going into practice staff and it's development - rather than the pockets of greedy GPs. Unless this changes, and soon, the future of QOF won't matter as there will be no practices left to undertake it.
Competing interests: No competing interests
Has the QOF improved population health? Has QOF saved lives? The chairman of the BMA's General Practitioners Committee (GPC) certainly thinks so. In 2009, five years after the implementation of QOF, Dr Laurence Buckman was quoted in the Jewish Chronicle as saying:
“The ‘quality framework’ that earns us a lot of money, I negotiated that. There happen to be fewer dead people as a result of that contract. About 8,500 people are not dead, where you would have expected them to die.” 
However, Gillam & Steele, in their useful review, were rather more circumspect when they said:
"QOF does promote important preventive activities but, against a background of many interacting determinants, we are unlikely ever to be able to attribute declines in death rates to a multifaceted intervention like the QOF."
The QOF has been a hugely expensive experiment and I also agree with Des Spence when he says:
"The QOF simply hasn’t worked. It is a bureaucratic disaster, measuring the measurable but eroding the all important immeasurable, and squandering our time, effort, and money." 
QOF is killing professionalism. Sadly, it seems that QOF has turned GPs into a braying herd of donkeys chasing carrots. It's time the QOF was killed off.
 He won GPs their big bucks. Michael Freedland, the Jewish Chronicle. http://bit.ly/Y2e6Ra Published 11 June 2009
 Kill the QOF. Des Spence, GP Glasgow. BMJ2013;346doi: http://dx.doi.org/10.1136/bmj.f1498. Published 6 March 2013
Competing interests: No competing interests
An insightful review, thank you. I continue to be concerned about gameplaying and what the data recorded by general practice teams means (1).
I am disappointed that the excellent work published by the Centre for Health Economics is not routinely referenced in reviews like this (2,3,4). I was interested to note that the most recent paper was not published in a Health Service related Journal
(2)Hugh Gravelle, Matt Sutton and Ada Ma Doctor behaviour under a pay for performance contract: Evidence from the quality and outcomes framework - http://www.york.ac.uk/media/che/documents/papers/researchpapers/rp28_doc...
(3)Hugh Gravelle, Matt Sutton and Ada Ma Doctor behaviour under a pay for performance contract: further evidence from the quality and outcomes framework - http://www.york.ac.uk/media/che/documents/papers/researchpapers/rp34_doc...
(4)Morris S, Goudie R, Sutton M, Gravelle H, Elliott R, Hole A, Ma A, Sibbald B, Skatun D. Determinants of general practitioners’ wages in England. Health Economics 2011;20:147-60.
Competing interests: My income depends upon QOF achievement.