QOF upper thresholds

The Marmot report on health inequalities, published a couple of weeks ago, had a few things to say on the subject of the QOF. Somewhat unsurprisingly it suggested that the QOF is used to reduce inequalities. One of the ideas mentioned, although not an official suggestion, was removing the upper threshold on QOF targets. I have to admit some sympathy to this idea in principle although it would certainly add to my work as a GP and the benefits are not entirely clear cut.

There are, however, a number of practical problems which could make implementation hard.

The biggest problem is one of funding. Currently practices receive a certain amount for each patient that meets the criteria between the lower threshold (currently mostly 40%) and the upper threshold (anywhere from 50-90%). If we want to expand that top threshold up to 100% there are a couple of ways of doing this. First we can keep the number of points the same. This means that the incentive per patient falls but the total potential cost to the government remains the same. Where thresholds are at 90% the difference will be 15% - enough to make some unhappiness but probably not earth shattering.

For DM 23 (diabetics with HbA1c less than 7) each patient will be worth a sixth of what they were before.

The other option is to keep the payment per patient the same. This is a lot more costly for the government. DM23 would need 102 points allocated to it (it has 17 at the moment) to keep up the incentive.

None of this takes account of exception reporting. As thresholds have not risen in this way before. It seems very likely that exception reporting would rise, but by how much? Would it incentivise exception reporting more than achievement? Might it simply lead to more organised exception reporting systems to send out the three letters? Most practices already get quite well over thresholds without the incentive of extra points.

And would it really reduce inequality? Could it make it worse? In the first years of the new contract practices in deprived areas did rather worse than those in less deprived areas, however they later caught up. Two years ago when moving the thresholds was mooted before extended hours came in I did some of the maths. It seems effects on practices are likely to be marginal only, but we won't know until it is implemented.

So not an absolutely awful idea but a lot of work would be needed before implementation.

There is more reaction reported at GP magazine.

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