QOF Consultation Response

The Deparment of Health have launched a consulation on "Role of incentive schemes in general practice". You have until one minute to midnight on the 7th of March to submit any comments you have, and please do so. I have copied my response below. Most of this was written before submission and so there are a couple of cases of free text where there was not a box to put it in.

Do you agree or disagree that incentives like QOF and IIF should form part of the income for general practice?

Agree

The QOF, and to a considerably smaller extent, the IIF, have contributed to a rise in data quality and some measures of quality of care. They should be considered together with Enhanced Services as part of the funding of general practice.

Whilst QOF and IIF are considered incentives and enhanced services (ES) are considered as commissioned this is not a distinction that survives to the provider level. If a commissioned service payment or an incentive payment is less than the cost of providing the service, then there will not be a business case for the practice to provide the service.

IIF has not proven successful and has been largely retired this year. If it survives, then it should be included in a single framework with ES and QOF. All of these must be considered within a larger commissioning framework. It makes little sense in the current contract that a single process can be paid through several different mechanisms.

Do you agree or disagree that QOF and IIF help ensure that sufficient resources are applied to preventative and proactive care?

Disagree

Most of the QOF is based around care of chronic conditions and the secondary prevention of complications of chronic disease. Public health measures and primary prevention have not been successful when these have been tried previously.

It should be considered a chronic disease management framework. Proactive care can be tackled in annual checks, but this is management of disease rather than prevention. There is an element of secondary prevention here but this has not been proven in rigorous studies.

Public health measures can be, and are, commissioned through enhanced services.

Would relative improvement targets be more effective than absolute targets at delivering improvements in care quality while also addressing health inequalities?

No. I would disagree strongly here.

Differential targets would appear unfair to practices and introduce perverse incentives which could be damaging to patient care.

Relative improvement targets would mean that practices could be paid different amounts for the same work. This would be unfair on practices. For the majority of QOF indicators practices start from zero at the beginning of the QOF year and build their achievement throughout the year until the following April. It is not the case that practices start from a higher level if they have had a higher level of achievement in the past, although they may have better processes in place.

This would also act as a brake on innovation. Practices which target work at a disease area and increase achievement in areas that subsequently become introduced into the QOF would be penalised with higher thresholds. Where an indicator remains in QOF for a few years then practices may be incentivised to vary their achievement from year to year, perhaps on a two year cycle, to maximise income.

The introduction to this question mentions an upper threshold of 85% leaving 15% of patients without incentives attached to them. The simplest solution is to move the upper threshold to 100% whilst leaving the lower threshold and the gradient the same. The main reason for not doing this would be the increased funding that may be required. There is no compelling reason to leave that 15% of patient without incentive.

If the upper and lower thresholds are too close together then this may reduce the incentive for practices and generate perverse incentives. In the current QOF the range between lower and upper thresholds for childhood vaccinations is small, although it has increased slightly in the most recent year. For practices with low achievement there is little incentive as they could have little chance of reaching the lower threshold. High performing practices also have little financial reason to improve. For other practices, the incentive is low for many patients but the patients between the thresholds can be worth hundreds of pounds each.

There are, of course, differences in populations and locations for practices which will influence how easy it is to deliver care. This is dealt with currently with a prevalence adjustment which will vary payment according to the specific disease burden. Adjustments for other social factors are properly contained in the global sum adjustment, although this has not been reviewed for nearly 20 years. Adjustments cannot reasonably be incorporated into an incentive scheme.

In what other ways could we use incentive schemes to address health inequalities?

Inequalities happen at a personal level and contracts operate at a practice level or above. Reconciling the two is likely to be very difficult. Solutions, such as prioritising practices with harder to reach populations is better done at the global sum level. Practices are unlikely to be willing to offer a differentiated service to different groups of registered patients.

There is potential for target enhanced services with specific focus but this should not be part of IIF or QOF.

To what degree, if any, do you think that ICBs should influence the nature of any incentive scheme?

Integrated Care Boards should be consulted on a national framework. This should be the core of any scheme. There may be potential to use a menu, as was the case of National Enhanced Services, but this is likely to be small.

There has been some attempt at local commissioning with Enhanced Services which, as I discussed earlier are broadly equivalent to QOF at the provider level. These varied in quality due to inexperience of commissioners. They have suffered from poor infrastructure support. The use of a menu of nationally supported services may help in that specific area.

There will always be practices at the geographical edges of ICBs that will have services which vary with their neighbours. There may be a perception of unfairness there and there may be a negative impact on services which are not incentivised in a particular area. They could be considered uncommissioned.

Do you agree or disagree that a PCN-level incentive scheme like IIF encourages PCN-wide efforts to improve quality?

Agree, but only to a small extent.

Incentives will work best if they are closer to the person whose behaviour you are trying to influence. PCNs are effectively a management structure so there is some sense in applying incentives there if it is the management that you are trying to influence.

PCNs are not the most efficient way to incentivise individuals – especially as some PCNs can be extremely large and incentives somewhat distant from clinicians.

What type of indicators, if any, within incentive schemes do you think most help to improve care quality? (Select all that apply)

Clinical coding (for example, accurate recording of smoking status in a patient record)

This is an effective use of incentive but the effect on care quality is not clear.

Clinical activity (for example, undertaking an annual asthma review)

This is probably all that you can do.

Clinical outcomes (for example, stroke rates)

Clinical outcomes are much too far removed from activity to be an effective incentive. We have mild version of this problem in the current QOF around shingles vaccination where there can be a decade between the incentivised action and the incentive being paid. This may be to someone else entirely, even in a different practice. It is also practically quite difficult to deal with the effects of patient death or emigration (in the latter case that would include moving to Scotland, Wales or Northern Ireland)

Quality improvement (QI) (for example, local project to improve patient experience or staff wellbeing)

This becomes so vague as to just be a commissioning effort which is better dealt with in an ES. These are pure process box ticks.

Do you think there is a role for incentives to reward practices for clinical outcomes measured at PCN or place level?

No

The incentives become so detached from the individual action that they cease to be incentives. Keep the incentive close to the person taking the action.

Do you agree or disagree that there is a role for incentive schemes to focus on helping to reduce pressures on other parts of the health system?

Neither agree nor disagree

The likely effect of any improvement in patient care is a reduced pressure on the health service but this should not be the primary motivation for this – that should be patient health. That is also likely to be a variable outcome which will only be apparent with large numbers of patients and difficult to attribute to any single actor.

Do you agree or disagree that incentives should be more tailored towards quality of care for patients with multiple long-term conditions?

Neither agree nor disagree

Whilst the aim is laudable specific indicators are likely to be difficult to create. They can end up being so vague as to be useless. They tend to say “do a review”, from which is very difficult to establish any evidence of benefit. The evidence for specific interventions in multimorbidity are poor.

Do you agree or disagree that patient experience of access could be improved if included in an incentive scheme?

Disagree

Creation of standards in this area would be very difficult in a way that is equitable. Of note is that there has been an attempt in this area in the past in the Patient Experience indicator. From 2009 to 2011 the PE 7 indicator was based on the number of patients who responded to the GP practice survey. This indicator did not last as it was not felt to be effective.

Any change patient perception of access is likely to require substantial resources, and this may be more that would be appropriate to commit to an indicator. Any real incentive is likely to require substantial change to the contract including payments for each type of patient interaction or appointment. Whilst this may be a direction that NHS England would wish to consider it is not something that would be part of an incentive framework.

Do you agree or disagree that continuity of care could be improved if included in an incentive scheme?

Disagree

There is no current indicator to measure continuity of care. Even survey results and patient perceptions have not been validated as measures. Any incentive payments could have the potential to produce unexpected incentives or results.

Any proposed indicators here would need to be piloted but the chances of producing a simple, clear and specific indicator are small.

Do you agree or disagree that patient choice could be improved if included in an incentive scheme?

Disagree.

Once again, the production of an effective indicator is likely to to be very difficult. Choice is often provided at referral management centres which are managed by ICBs. Wherever it happens it is difficult to measure. Choice is likely to vary significantly between different areas of the country. Choice is easier in areas with higher densities of providers. This will be an area that is better dealt with at the ICB level.

Do you agree or disagree that the effectiveness of prescribing could be improved if included in an incentive scheme?

Agree

Prescribing is an area that has been the subject of indicators in both the QOF and IIF in the past. A stable multi-year approach is most successful – incentives for practices to change are higher if there a snowball effect on treatment. We have seen this effect in QOF around the use of statins and the use of medication in left ventricular systolic heart failure.

An example of how this does not work was the transfer to edoxaban which was included in the IIF in 2022/23. This was a purely financially driven indicator which was dropped after a year as the financial situation changed. The changes from this indicator were quite small. 

Prescribing data from OpenPrescribing

If you think there are any other areas that should be considered for inclusion within an incentive scheme, please list them here.

There is some potential for safe prescribing measures to be used. This is mostly avoiding things so would effectively be an “upside down” indicator where a lower percentage is scored more highly.

What opportunities are there to simplify and streamline any schemes for clinicians, and reduce any unnecessary administrative burden, while preserving patient care?

The best way to avoid “tick box” indicators are simply not to introduce them in the first place. Whilst there are many aspects of practice that it might be considered desirable to incentivise in practice it is important to also consider the quality of the indicator for that area. An important area with poor quality or indirect indicators should not be included – other contractual mechanisms should be used to deliver these improvements.

The difference between item of service payments and incentive payments is small and there is they should be considered in the same way. Bringing all performance related searches and payments, including immunisations, into a single framework would greatly reduce the boxes that need to be ticked. For example, there are currently four or five payments linked to influenza vaccinations which are claimed through three different systems. This is time consuming, costly to administer and entirely unnecessary.