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Removing QOF not detrimental to patient care

Clinical performance generally remains stable long after incentives withdrawn

Louise Prime

Wednesday, 29 January 2014

Clinical performance generally remains stable long after financial incentives are withdrawn, research has shown. Authors of the study, published on bmj.com, suggest that Quality Outcomes Framework indicators for which performance has reached high levels could periodically be replaced, to increase health benefits in other areas.

Researchers in Manchester and elsewhere used data from the Clinical Practice Research Datalink, covering almost 14 million patients in 644 general practices in England, to assess the impact of the introduction and removal of QOF indicators. They looked at performance on eight clinical quality indicators for seven chronic conditions – asthma, coronary heart disease, chronic obstructive pulmonary disease, diabetes mellitus, epilepsy, severe mental health (psychotic illness), and stroke – that had initially had indicators in the QOF scheme that were subsequently removed. They also analysed data for hypertension, which had retained a quality indicator measuring a process similar to one incentivised in the removed indicators.

They found that, in general, performance did not decline after incentives were removed – in either the short or the long term. They wrote: “For the two indicators removed in April 2006, levels in 2011/12 were very close to 2005/06 levels, although a small but statistically significant drop was estimated for influenza immunisation. For five of the six indicators withdrawn from April 2011, no significant effect on performance was seen following removal and differences between predicted and observed scores were small. Performance on related outcome indicators retained in the scheme (such as blood pressure control) was generally unaffected.”

The study’s authors suggest this apparent stability might be a result of staff regarding those activities as routine, and of patients having higher expectations based on previous years’ experiences. But they warn that, in some cases, the level of clinical performance did drop below that expected, “suggesting that withdrawing incentives is not without risk”. They also point out that some of the indicators that they investigated were still incentivised, indirectly or partially, by other indicators still in place.

They concluded: “Our findings indicate that withdrawing incentives for aspects of care for which performance has reached high levels and reinvesting in alternative aspects of care could provide an opportunity to drive improvement in the latter without greatly damaging quality of care in the former, thus maximising health benefits from incentive schemes. However, generalising the findings to all incentivised aspects of care would be premature, and careful consideration needs to be given to aspects of care for which financial incentives are to be withdrawn.”

doi.org/10.1136/bmj.g330

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