Intended for healthcare professionals

Rapid response to:


Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study

BMJ 2009; 338 doi: (Published 27 May 2009) Cite this as: BMJ 2009;338:b1870

Rapid Response:

QOF Effects Across Lothian

Since the introduction of the QoF system in 2004, studies either
promoting or negating its effect have been relatively frequent. Even if we
refine this to the QoF impact upon diabetes care alone, there is still a
wealth of interest, suggesting that this is an area of much controversy.
This controversy has recently been amplified further by the amendment of
one the QoF HbA1c targets
for diabetics (HbA1c ≤7.0% as of April 1st 2009). A recent study carried
out by my colleagues and I aimed to examine this in more detail.

In your article it is said that "the impact of the quality and
outcomes framework on care [of diabetes]
is not straightforward" and in our opinion this hits the nail on the
head. Previous work done by Tahrani et al (2007) found there to be
"significant improvements" in all quality indicators after the
introduction of QoF. However, this study also suggests that the QoF system
itself "may not have been responsible" for such a change, and therein
lies the rub. Can we really give credit to the QoF
system for our 21st century health improvements?

Our study looked at GP practices across Lothian to assess the impact
of the new QoF HbA1c target of ≤7.0% on the 29,934 diabetic patients in
the area. In particular, we aimed to discover if the new target would
disproportionately disadvantage the deprived population of Lothian.

Before the revised target, despite the discernable differences in
HbA1c attainment between affluent
and deprived practices, this could not be said to disproportionately
disadvantage deprived practices
as both sets met the HbA1c target of ≤7.5%.

We found that the introduction of an HbA1c target of ≤7.0% would
reduce the proportion of
patients in both affluent and deprived practices meeting the QoF target.
However, significantly, the
introduction of this target will mean practices in deprived areas failing
to reach the target. This
outcome suggests that deprived practices will be disproportionately
disadvantaged by the revision of
the HbA1c target.

This is just one example of how the QoF system is anything but
"straightforward", and highlights the
need for further investigation into its effect.

1. Tahrani et al. Diabetes care and the new GMS contract: the
evidence for a whole county. Br J Gen Pract. 2007;57(539):483–85.

No Competing Interests

Competing interests:
None declared

Competing interests: No competing interests

27 October 2009
Kieran Montgomery
Medical Student
Ian JB Young, Dan Pugh, Manreek Basi, Bruce T McLintock
Edinburgh Medical School EH16 4SB