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QOF: Payments by results

QOF: Payments by results

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The large amounts of data produced by incentive schemes such as the Quality and Outcomes Framework has proved to be an attractive target for researchers. The two areas most researched have been measures of quality of treatment and the effectiveness of the QOF itself.

There was a bit of publicity about one paper looking at value for money in the QOF. That it was co-authored by a member of the QOF NICE advisory committee - Dr Nicholas Steel - only made it more relevant.

It is not a difficult read and the main message is that the incentives for each indicator are not related to the potential health benefits arising  from achievement of the indicator - at least for those indicators where there is enough evidence to calculate the financial benefits.

As Dr Steel is on the committee that proposes the indicators it is tempting to ask what he is planning to do about it. This would be a bit unfair though as NICE does not suggest the thresholds or point value - that is done by the negotiators later on. NICE actually go as far as producing a cost benefit analysis for each new indicator.

The suggestion is that practices may end up doing some of the less useful stuff at the expense of the more clinically useful targets. There is no direct evidence of this, but it is not an unreasonable thought and probably worthy of further research.

The paper suggests that the incentives should be a lot closer to the health benefits. This is attractive - in theory at least. Incentivising the most effective interventions seems sensible.

Practically, it would mark a significant change in the way that the QOF is paid. These changes would, presumably, see the value some indicators go up whilst others would go down. If we suppose that indicators are priced according to workload at the moment (and that is a pretty big supposition) them some indicators would be priced under workload, and some over.

Practices would effectively become little NICEs trying to work out whether the benefit, clinical and financial, outweighed the cost. Some indicators would simply not be cost effective for practices to deliver.

Other indicators would be paid above workload. As a working GP, this would seem fantastic although the tax paying part of me is not so sure.

The best option would be to get rid of the indicators in QOF that are not cost effective.

Unfortunately for Dr Steel and the NICE committee they have not been particularly successful at this. The committee considers the cost effectiveness of all its suggestions. Of the nine indicators recommended by NICE for removal from the QOF this year only one was actually removed by the negotiators.

It is absolutely right to question the usefulness and cost effectiveness of QOF indicators. Achievement has always tended to be lower where there is significant doubt among GPs about the usefulness of an indicator. Depression and chronic kidney disease have been examples of this.

Perhaps it is time to get back to a thoroughly evidence based QOF.

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