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Blog: The future of QOF

Blog: The future of QOF

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QOF has seen many changes since its introduction in 2004. Dr Gavin Jamie explores what could come next for the 'friendless' system

On the first of April 2004 the quality and outcomes framework (QOF) came into being along with the rest of the new GMS contract. According to Wikipedia in that same week Usher was at number one in the singles chart with Yeah. Tony Blair had recently returned from meeting Colonel Gaddafi in Libya. It was clearly a very different time.

Things were different in general practice. There was really very little information about what happened in the surgery. There were occasional audits but these were far from universal and this frustrated managers at the new primary care trusts, health economists and politicians alike.

It was a time of increased funding of the health services and the chancellor, Gordon Brown, was keen that there should be clear results from the increased funding. Where practices income was based on capitation there was a feeling that GPs were paid for quantity rather than quality and so the QOF was born.

Back then the QOF had 1,050 points with 56 clinical indicators, alongside the organisational domain, the access bonus and slightly bewildering holistic bonus.

In 2013 almost none of the factors that led to the introduction of QOF are still in place. Practices are being examined from almost every angle. While no patient identifiable information left the practice in the QOF assessments the NHS is about to start the largest ever extraction of patient data from practice systems.

The number of disease areas, indicators and the complexity of each indicator have all increased markedly. A large number of points have moved to the quality and productivity indicators which cover areas very different from the original intentions of the QOF, largely rewarding a series of meetings. There are now only 900 points and in many cases the value of each point has been eroded by increased disease prevalence.

There are a very limited number of new indicators being proposed by NICE next year and these are largely about maintenance to the existing QOF rather than taking us into new areas. Several of the existing indicators - most notably the general practice physical activity questionnaire exercise - are seen as little more than box ticking exercises.

There are few friends of the QOF as it stands. Jeremy Hunt has pledged to reduce the box ticking and bureaucracy of the current GMS contract - my practice ticked over twenty five thousand boxes in 2011/12, and there are likely to be more this year. The British Medical Association's General Practitioners Committee has expressed much the same view and most of the GPs that I have spoken to tend to agree.

With such unanimity it seems unlikely that QOF will remain entirely in its current form from 2014. However, QOF is worth such a large proportion of practice income that the fate of the cash is critical and this could be a much bigger issue in the contract changes than the reduction in QOF. 

Ideally it would be moved into the global sum - after all the work will still need to be done. 

There could be, and not for the first time, an attempt to spend the same money twice. Indeed it was this dilution of resources that did as much as poorly evidenced indicators to turn GPs against the QOF. Trying to stretch quality payments into quantity would discredit any new initiative. 

It should be clear from the last few years that GPs can be very effective at responding to the priorities implied by the contract. 

It will be up to NHS England what those priorities will be.

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