Incentivising public health in primary care: learning from the QOF

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Good primary care is critical to public health and tackling inequalities. The previous government recognised this with a strong focus – through the Health Inequalities National Support Team – on supporting primary care to intervene more systematically and at scale in its primary and secondary prevention role.

It also introduced the Quality and Outcomes Framework (QOF), the largest pay-for-performance incentivisation scheme in primary care anywhere in the world. Today we publish our research findings on QOF and its impact on public health.

The good news is that we found QOF has been successful in incentivising a more organised approach to chronic disease management and secondary prevention. QOF has also encouraged more deprived practices and those that were more disorganised or lacked resources to adopt a more systematic approach. In common with other studies, we found that QOF attainment between the least and most deprived practices has narrowed and all but disappeared over time, with no evidence that exclusions were being made to maximise rewards.

Not such good news from our study is a lack of evidence that QOF has directly improved health or reduced inequalities. QOF also provides no incentive for primary prevention or case-finding and practices with more deprived patients are failing to identify all cases of disease within their practice populations. QOF is also not working well for particularly vulnerable groups with great public health needs, such as the homeless and travellers. More generally, we found that QOF encourages a clinical and mechanised approach to managing chronic disease that does not support holistic care or promote self-care and management.

Future revisions of QOF need to provide more incentives for primary prevention and inequality reduction. Its reward structure must do more to promote case-finding and encourage a patient-centred approach to chronic disease management by incentivising effective self-care and management and reflecting that many patients have multiple co-morbidities. Other mechanisms beyond QOF need to be developed for the care of particularly vulnerable patients. The Department's Inclusion Health agenda – that focuses on those groups – will be critical to that.

Our recent response to the proposed public health reforms considered the impact that transferring the main responsibility for public health to local authorities will have on primary care's contribution to prevention. Primary care's critical role in prevention should not be allowed to drift. Future revisions of QOF will be one test of whether or not that is happening. It is not a good sign, however, that the Department of Health has withdrawn funding for the National Support Teams that were supporting primary care trusts to systematically target inequality reduction in primary care.



Service Development Manager,
New Zealand
Comment date
12 May 2011
These outcomes may align with the outcomes being experienced in our QOF equivalent here (PPP). Unfortunately, the PPP is a small component of the funding for Primary Care here, and this means our leverage to improve care is less direct.

James P. Scanlan

Comment date
05 May 2011
A general problem with efforts to appraise the impact of improvements in healthcare on healthcare inequalities is the failure to recognize the way that measures of differences between rates are affected by the overall prevalence of an outcome. Improvements in care tend to lead to higher procedure and appropriate care rates. When this occurs, solely for reasons related to the shapes of the underlying distributions of factors associated with likelihood of receiving some type of care, relative differences in receipt of such care tend to decrease and relative differences in failing to receive such care tend to increase. Absolute differences between rates and odds ratios tend also to be affected by the overall prevalence of an outcome, though in a more complicated way. Roughly, where an outcome is uncommon (less than 50% for all groups being compared) increases in the outcome tend to increase absolute differences between rates; where an outcome is already common (more than 50% for all groups being compared) further increases in the outcome tend to reduce absolute differences between rates. Differences measured by odds ratios tend to change in the opposite direction of absolute differences between rates. Unless these patterns are fully understood, it is not possible to soundly appraise effects of healthcare improvements on healthcare inequalities and it is a mistake to tie performance payments to perceptions of changes in healthcare inequalities.

Marc Rowland

SE London
Comment date
21 April 2011
The principles of QOF have, in my experience, been embraced by most GPs for clinical not financial reasons but it must also be intelligent and reflect trailing edge, established opinions that will not change in 1y as HbA1c.
The element missing in it is caring continuity as against caring functionality as an in Iona Heath's eloquent piece on your report BMJ2011;342:doi:10.1136/bmj.d2254 (Published 13 April 2011)

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