Introduction. Strong primary care is a prerequisite of cost-effective, equitable health systems and better population health (1). Introduced to the National Health Services of the four United Kingdom (UK) countries in 2004 for general practice, the Quality and Outcomes Framework (QOF) is the most comprehensive national primary care pay for performance (P4P) program in the world (2). Each of the four countries comprising the UK has its own tax-funded national health service, which, overall, totals with approximately 40,000 practitioners working in around 10,000 practices.
The P4P program, here referred to as the QOF or the framework, is a complex intervention comprising several elements which uses financial incentives to promote structured and team-based care in pursuit of evidence-based objectives. The different clinical and organisational domains to which payments are linked are shown in Table 1. There are a maximum of 1,000 points available; in 2009-2010, practices earned on average 126.77 pounds per point. Payments are adjusted for recorded disease prevalence. For example, hypertension indicator (BP5) - the percentage of patients with hypertension (measured in the previous 9 months) in whom the last blood pressure is 150/90 or less - attracts 57 points. Most of these P4P payments link to evidence-based process measures related to the quality of chronic disease management. A sensible verdict regarding the QOF's effectiveness must balance a nuanced assessment of health and other gains against its costs, many of which are hard to describe let alone quantify (3).
The QOF's Impact. The QOF's impact is described under the following five headings:
- Quality of health care. There are early indications that the framework has resulted in better recorded care, enhanced processes, and improved intermediate outcomes (e.g., the control of HbA1c and high blood pressure in people with diabetes) (4). It has helped consolidate evidence-based methods for improving care by increasing the use of computers, decision support, provider prompts, patient reminders, and recalls (5).
- Population health and inequalities. While the framework was not designed to reduce health inequalities resulting from socioeconomic disadvantage, inequalities of care between the most and least deprived areas have narrowed. For example, Doran and colleagues showed that variation in reported achievement decreased at a faster rate for practices in the most deprived areas across all 48 individual indicators during the first three years of the framework (6). In fact, the QOF does encourage greater consistency of care irrespective of deprivation (7). Additionally, there are estimates indicating significant population mortality reductions (8). A modeling study estimated that the potential reduction in mortality from full implementation of the QOF contract was 416 per 100,000 people per year in 2004-2005, and 451 in 2006-2007. The potential reduction in mortality per 100,000 people per year ranged from 163 in coronary heart disease, to 8 in asthma (9).
- Team structures and ways of working. The QOF has resulted in positive effects on practice organisations, such as on team-work (e.g., the development and use of shared protocols) and the diversification of nurse roles (e.g., sub-specializing in different clinical areas). Indeed, the transition to a nurse-led primary care system is accelerating under the QOF in various ways. The QOF has introduced new hierarchies within practice teams and helped stratify medical roles (10).
- Patient views. Remarkably, little is known of what patients actually make of these changes. Adherence to single, disease-based guidelines can override respect for patient autonomy and ignore the co-morbidities that are today's norm (11). By focusing the clinician's attention on sometimes extraneous targets and the completion of computer templates, the QOF can promote a mechanistic approach to chronic disease management at the expense of personal care. This is nicely illustrated in the accompanying vignette provided by a patient (Box 1).
"A slim, active 69-year-old patient presenting with a request for influenza vaccine was faced with questions about diet, smoking, exercise and alcohol consumption. There was no explanation for why these questions were asked; they seemed irrelevant to having a flu vaccine. Blood pressure and weight had to be recorded and a cholesterol test organised. A short appointment lasted almost 15 minutes without the patient having the opportunity to ask a question about any aspect of flu vaccine." (12)
- Cost-effectiveness. A central question is not whether the QOF has had an impact, but rather concerns the QOF's cost-effectiveness; here, the evidence is sparse. Indicators in some domains may prove cost-effective (13). For example, evidence shows that increasing the quality of primary care may reduce hospitalization rates for some conditions (14). The average net income of family practitioners is in the region of 100,000 pounds ($150,000) of which these payments make up just under a quarter. More sophisticated modelling is required, but the opportunity costs of the QOF are, by any reckoning, considerable.
Critiques. This provides the central critique for the QOF's detractors. If 1 billion pounds a year has yielded only modest improvements in measured quality of care, could other means and other staff achieve similar results?
In many cases, improved performance on clinical indicators was in-line with increases that might have been predicted on the basis of secular trends prior to introduction of the QOF. To what extent these improvements are the vicarious result of improved recording (i.e., improved documentation of performance rather than changes in performance) remains unclear (15). What is clear, however, is that commercially constructed evidence is driving up prescription rates for antidepressants, statins, and other drugs with little evidence of improvement in proxy outcomes (16).
Incentives were not aligned to address inequalities in health. Other factors limit the QOF's impact at population level. For example, the process of 'exception reporting' permits the exclusion of patients whose preferences, circumstances, or contraindications make the recommended care inappropriate. Setting targets below 100% and the allowance of exception reporting reduces the public health effectiveness of population targets by shifting the focus of the practice away from harder-to-reach patients. More fundamentally, we cannot assume that payment for adhering to guidelines will improve health status, regardless of whether it improves 'performance'. The QOF's evidence base will only ever be partial.
For many doctors and nurses, the impact of computerised templates has been intrusive. People become codes, and continuity of care is fragmented as patients return to multiple disease-specific clinics (17). For many practices, clinical governance, required audits, and the QOF have become synonymous. Quality of care narrowly focuses on QOF domains and indicators to the exclusion of other areas for practice development, innovation, and quality improvement.
In historical terms, the QOF represents a high water mark in the onward march of what Harrison has termed 'scientific bureaucratic medicine' (18). Indicators and guidelines threaten professionalism in various ways (19). Doctors and nurses may perceive the QOF as ceding control of clinical practice to 'experts' and reducing clinical autonomy. It has provided commissioners with blunt tools for comparing providers and crude performance management.
Practices are run as small businesses. When medical members of the primary health team need replacement, salaried doctors and nurses with specialist skills are increasingly seen as more cost-efficient than the conventional profit-sharing principal. Among several perverse consequences, the QOF may, by fostering primary care as a commodity, pave the way to its privatization. Market-oriented health systems are viewed — at least in the UK — as both less efficient and liable to neglect the primary care sector (11).
Ways Forward. The wisest course is to concentrate on addressing the criticisms rather than throwing away the gains:
- Indicator development. There will always be a fine judgment about timing, level of evidence required, and whether to accept a consensus rather than evidence-based indicator. An argument for greater consistency of care should not prevail where evidence is lacking. The evidence base for existing indicators needs to be under constant review. Some indicators for which performance has reached a ceiling may need retirement (20), and new indicators should be introduced after piloting (21). The involvement of the National Institute for Health and Clinical Excellence (NICE) has greatly strengthened the QOF's scientific underpinnings (22). (An 'expert panel' has been replaced by a 30 strong advisory committee that prioritizes indicators on the basis of evidence. A two-stage RAND appropriateness method involving frontline practitioners (GPs) then rates them prior to piloting in 30 representative practices.)
- Vigilant monitoring. 'Gaming' — the manipulation of data in order to increase financial rewards — is known to occur in many systems that are driven by P4P. However, little evidence of gaming exists in the framework despite, or perhaps because of, a rigorous system of checks at various levels (23). On the contrary, practices are exceeding the upper payment thresholds, and levels of exception reporting continue to fall year on year (24). Nevertheless, systems to detect and prevent gaming are needed.
- Scaling back financial incentives. The balance of fixed versus performance-related funding may be wrong. There is evidence that the structural changes to practice systems may have led to similar outcomes but with lower levels of incentive (25). There is merit in linking the size of financial rewards to the public health impact of attaining individual indicators.
Further Research. The framework is by no means a perfect system for improving quality — it needs improvement and modification based on careful analysis of its effects, both intended and unintended, and the ever-changing evidence that underpins it (26). Thus far, numerical data suggest some early improvements in quality of care attributable to the QOF, while interview-based data reveal a mixed picture in areas (e.g., professionalism, continuity of care) that are ever difficult to quantify. Research needs also to include comparative analyses between health systems as more countries introduce similar pay for performance schemes.
Stephen J. Gillam, MD, FRCP, FRCGP
University of Cambridge, Cambridge, UK
The views and opinions expressed are those of the author and do not necessarily state or reflect those of the National Quality Measures Clearinghouse™ (NQMC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor, ECRI Institute.
Potential Conflicts of Interest
Dr. Gillam reports the following personal/financial interests: executive partner at Lea Vale Medical Group; shareholder/board member of Local Health Solutions.
Dr. Gillam reports the following business/professional affiliations: Fellow, Royal College of General Practitioners; Fellow, Royal College of Physicians; Fellow, Faculty of Public Health.
Dr. Gillam declared no family member conflict of interest or additional disclosures.
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Table 1. Domains of the Quality & Outcomes Framework