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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.