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Blog: Slicing QOF

Blog: Slicing QOF


The current situation is unsustainable. Carrying on as we are is not an option. We need to change what we do and how we are doing it.

This seems to be the general view on almost anything at the moment. From pensions to commissioning and primary care, the view is almost the same. Of course the details are different in each case and there has almost always been someone, somewhere predicting the end of things.

What seems new is the almost unanimity at every level of this belief. So universal is this belief that, even after all of the previous predictions of the end, I am almost starting to believe it.

Could we really have built a health service that can’t work?  How have we done this - is it inevitable?

In general practice the biggest issue currently is workload. Patient demand is increasing along with greater pressure from above. Practices are pinched in the middle.

Looking to the future there is a perfect storm of paperwork seen to be approaching at the end of the year with CQC registration and revalidation due to hit almost simultaneously.

One of  the most frequent complaints is the increasing complexity of QOF. What started as a fairly simple system has become has greatly increased in scope. New clinical areas have been added by slicing points from existing indicators. Increasing prevalence has eroded the value of points in some areas.

The structure of the indicators has become increasingly complex without much evidence of benefit to anyone other than QOF writers trying to explain them. The recently added indicators for atrial fibrillation are some of the most convoluted yet. NICE have consulted about an even more complex form of indicator to start in 2013.

The change has been gradual and most practices have adapted - points scores have stayed relatively high. The changes have been described as efficiency savings and, from the point of view of the NHS they have been exactly that - more has been achieved with the same money.

For individuals, clinicians and practices there have been diminishing returns with the same money taking more time and effort to earn.

While there are always efficiencies that can be made, it is a seemingly common belief in some senior NHS managers that this means efficiencies are infinite and can fill any gap that happens to appear on your spreadsheet.

Salami slicing seems has become a standard NHS procedure.

There does not appear to be a problem so much as a systemic dysfunction. It seems that it is not the structure of the NHS that is the problem but rather the materials we are using to build that structure.

The use of targets has certainly had a positive effect on the NHS when cash increased. It remains to be seen if they will have a constructive or destructive effect when budgets get tighter.

The instinct to add more monitoring and regulation is no longer useful. The line between optimum efficiency and unviability is razor fine and slightly different for every practice. Primary care will not collapse, but may fade away.

If delivery is unsustainable then commissioning will never become so.


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