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• W2953043474 abstract "Areview of the Quality and Outcomes Framework (QOF) in England recently concluded that a significant refresh would be desirable to support a broader definition of high-quality care, recognise changes in clinical evidence and align better to professional values.1 Changes to the diabetes indicators outlined in Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan came into effect in April of this year. Six diabetes indicators have been retired and replaced with five indicators worth 43 points. These changes are intended to reduce iatrogenic harm and improve outcomes in diabetes care. It is stated that the new indicators will reduce the potential of over-treatment of patients with moderate to severe frailty by intensive glucose lowering, with achievement focusing on lower glucose targets in this patient population. The need to record erectile dysfunction in male patients with diabetes will also cease.2 QOF was initially introduced universally in general practice across the UK in April 2004 as an ambitious, incentivised scheme to improve the quality of care by the adherence to evidence-based clinical indicators. Diabetes was one of the main disease categories with initially 18 indicators based on the widely-recognised approaches to the care of diabetes.3 In the initial years, achievement improved along with practice income and morale, although a ceiling was soon reached.4, 5 The increased income allowed the introduction and development of structured disease management clinics within primary care, as well as delivering on higher quality. The regular reviews were popular with patients with long-term conditions who appreciated the ongoing monitoring they received. Over the years, QOF became less popular. It came to be seen as a bureaucratic ‘box ticking exercise’ with greater biomedical focus, and there was concern that non-incentivised care was receiving less attention. Professionals felt that it detracted from their clinical autonomy with a noticeable behaviour change in order to achieve the targets for financial gain, at a time when the management of long-term conditions was becoming more complex. Morale was not helped by the introduction of indicators of dubious clinical value and READ codes changes used to define diabetes is given as an example of poorly thought out changes.5 The biggest problem has been demonstrating the effectiveness of QOF. Modelling revealed that stopping QOF and leaving the funding within the NHS was more cost effective and that, to improve population health efficiency, QOF needed to be redesigned or replaced with alternative interventions.6 One study did not show that QOF addressed ethnic disparities in diabetes outcomes7 despite having the potential to improve inequalities in primary care.8 QOF may have initially accelerated the improvement in quality of diabetes care but the effect subsequently plateaued.9 A decrease in hospital admissions for incentivised conditions has, however, been observed.10 Research has not been able to demonstrate a mortality benefit or improved cardiovascular outcomes.11 This may reflect that the benefits of indicators derived from randomised controlled trials are not immediately apparent in day-to-day clinical practice. In the years following the introduction of QOF, payments accounted for up to 20% of practice income. In England this has now reduced to 11% in some areas, whereas in others where local incentive schemes have been introduced it can be less than 1% of income.12 In England the broad consensus was for the evolution of QOF.2 In Wales pending an overhaul of the General Medical Services (GMS) contract, in order to relieve workload pressures, the vast majority of QOF indicators were inactivated for 2018/19 although the requirement to maintain disease registers remained.13 On 1 April 2016, QOF in Scotland was dismantled and the funding moved to the global sum.14 It has been noted that, when financial incentives have been removed from glycaemic control and screening for diabetic retinopathy, performance levels declined.15 The retirement of QOF indicators has previously resulted in an immediate decline in the performance of those quality measures.16 In the last year that QOF data were available for Scotland (2015/16), 98% of the points for diabetes were achieved17 compared with 91% for England in 2017–18, the latter a fall of 0.9% from the previous year.18 Scotland has led the way in the collection of diabetes data and the Scottish Diabetes Survey contains core information from over 99% of people diagnosed with diabetes in Scotland.19 In his forward to the 17th report, the chairman of the Scottish Diabetes Data Group acknowledges that the gradual decline in the delivery of all processes of care for people with diabetes may in part be due to the change in the QOF funding for general practice. He did, however, comment that the specialist diabetes services are also not delivering on the nine processes of care. The loss of QOF may also have a negative effect on any local incentivised approach. In Tayside the percentage of people with diabetes who had a foot risk score in the 15 months to end of March 2018 has declined to below the national target of 80% to 77.8%, from a high of 89.1% in the 15 months to the end of March 2016.20 In Scotland the loss of QOF has markedly reduced the administrative burden at a time of increasing workload but without any increase in morale or recruitment. Chronic disease monitoring in practices now has a much lower priority. QOF has been replaced by a requirement for GPs to take part in local peer-led quality improvement activities through practice clusters.21 A few cluster groups may be working well but, with the loss of a national approach, they are unlikely to reverse the current decline in the parameters of diabetes care. For meeting quality standards in primary care and improving patient outcomes evolution may be the better approach. There are no conflicts of interest declared." @default.
• W2953043474 created "2019-06-27" @default.
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• W2953043474 date "2019-05-01" @default.
• W2953043474 modified "2023-10-16" @default.
• W2953043474 title "Life after QOF" @default.
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• W2953043474 doi "https://doi.org/10.1002/pdi.2219" @default.
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