Professor Mike Pringle presented on the impact of the Quality and Outcomes Framework (QoF) in the UK. He addressed whether QoF improved health outcomes, reduced inequality gaps, and was cost-effective. While some metrics like blood pressure monitoring rates increased after QoF, improvements were already occurring before 2004. QoF initially widened inequality gaps but practices in deprived areas were exempted, and gaps have since narrowed. Potential downsides include reduced professionalism and displaced activities, but exemption code use has declined. Whether QoF is cost-effective is debated as effects of socioeconomics on health are greater than QoF incentives.

1. Professor Mike Pringle, Valencia, 24th June 2010
THE IMPACT OF THE QUALITY AND
OUTCOMES FRAMEWORK
Professor Mike Pringle
Professor of General Practice
University of Nottingham

2. Professor Mike Pringle, Valencia, 24th June 2010
Questions to address
• What was the overall effect of the
introduction of QoF?
• What effects on inequalities?
• Any other unintended disbenefits?
• Is QoF cost-effective?

3. Professor Mike Pringle, Valencia, 24th June 2010
What was the overall effect of the
introduction of QoF?
• Qresearch1 analysis shows higher
prevalence of key conditions
• And improvement in between pre- and
post-QoF

4. Professor Mike Pringle, Valencia, 24th June 2010

5. Professor Mike Pringle, Valencia, 24th June 2010
What was the overall effect of the
introduction of QoF?
• And.... % of adults with up to date BP
monitoring up from 82.3% in 2005 to
88.3% in 20072

6. Professor Mike Pringle, Valencia, 24th June 2010
What was the overall effect of the
introduction of QoF?
• But.... QoF metrics were improving
before 2004 in diabetes3 and other
QoF conditions4.
• In CHD, the percentage of patients
with BP controlled rose from 47% in
1998 to 72% in 2003; and cholesterol
controlled from 18% in 1998 to 61% in
20035

7. Professor Mike Pringle, Valencia, 24th June 2010
What was the overall effect of the
introduction of QoF?

8. Professor Mike Pringle, Valencia, 24th June 2010
What was the overall effect of the
introduction of QoF?
• Improvements in diabetes QoF
indicators after 2004 were not great6

9. Professor Mike Pringle, Valencia, 24th June 2010
What effects on inequalities?
• There were fears that the better
practices in the least deprived areas
would perform best, increasing the
inequality gap (and disparity in GP
income)

10. Professor Mike Pringle, Valencia, 24th June 2010
What effects on inequalities?
• There were lower QoF scores in more
deprived areas7 and initially there was
evidence for a widening of
inequalities8,9

11. Professor Mike Pringle, Valencia, 24th June 2010
What effects on inequalities?
• But... Due to exemption codes,
practices in deprived areas have not
been penalised10

12. Professor Mike Pringle, Valencia, 24th June 2010
What effects on inequalities?
• And average levels of achievement
have increased over the first three
years of QoF, and the variation has
diminished 11:
Year Quintile 1 (least) Quintile 5 (most)
2004/5 86.8% 82.8%
2006/7 91.2% 90.4%
Difference +4.4% +7.6%

13. Professor Mike Pringle, Valencia, 24th June 2010
What effects on inequalities?
Average score (% ) against deprivation
100%
95% 2004-5
90% 2008-9
85%
Q1 - areas with Q2 - areas with Q3 - areas with Q4 - areas with
lowest middle lowest middle highest highest
deprivation deprivation deprivation deprivation
Quartiles

14. Professor Mike Pringle, Valencia, 24th June 2010
What effects on inequalities?

15. Professor Mike Pringle, Valencia, 24th June 2010
Any other unintended disbenefits?
Proposed disbenefits include:
• Reduction in professionalism (box
ticking)12,13
• Gaming12,14
• Patient coersion12
• Displacement of other, more useful,
activities12

16. Professor Mike Pringle, Valencia, 24th June 2010
Any other unintended disbenefits?
But.... Use of exemption codes
decreased markedly in the second
year and remains low14

17. Professor Mike Pringle, Valencia, 24th June 2010
Is QoF cost-effective?
• £1bn per year (20% of general
practice income)15 but most would
have been paid anyway
• Could be argued that good care
should have been core, not requiring
incentives
• Effects of socio-economics is much
greater than any effects of QoF16

18. Professor Mike Pringle, Valencia, 24th June 2010
Is QoF cost-effective?
It is your decision!

19. Professor Mike Pringle, Valencia, 24th June 2010
References:
1. Time series analysis for selected clinical indicators from the Quality and
Outcomes Framework 2001-2006. Hippis;ey-Cox J, Vinogradova V,
Coupland C. Qresearch, 2006
http://www.qresearch.org/Public_Documents/Time%20Series%20Analysis
%20for%20selected%20clinical.pdf
2. Ashworth M, Medina J, Morgan M. Effect of social deprivation on blood
pressure monitoring and control in England: a survey of data from the
quality and outcomes framework. BMJ, 2008;337:2030
3. Khunti K, Gadsby R, Millet C, Majeed A, Davies M. Quality of diabetes care
in the UK: comparison of published quality of care reports and the results of
the Quality and Outcome Framework for diabetes. Diabetic Medicine,
2007;24:1436-1441
4. Roland M. The Quality and Outcomes Framework: too early for a final
verdict. BJGP, 2007; 57:525-527
5. Campbell S, Roland M, Middleton E, Reeves D. Improvements in the quality
of clinical care in English general practice 1998-2003. BMJ 2005; 331:
1121-1123

20. Professor Mike Pringle, Valencia, 24th June 2010
6. Calvert M, Shankar A, McManus R, Lester H, Freemantle N. Effect of the
quality and outcomes framework on diabetes care in the United Kingdom:
retrospective cohort study. BMJ, 2009; 338:1870
7. Ashworth M, Armstrong D. The relationship between general practice
characteristics and quality of care: a national survey of quality indicators
used in the UK Quality and Outcomes Framework 2004-5. BioMed Central,
2006; 7:68 doi:10.1186/1471-2296-7-68
8. Wright J, Martin D, Cockings S, Polack C. Overall Quality and Outcomes
Framework scores lower in practices in deprived areas. BJGP, 2006; 56:
277-279
9. Ashworth M, Seed P, Armstrong D, Durbaba S, Jones R. The relationship
between social deprivation and the quality of primary care: a national survey
using indicators from the UK Quality and Outcomes Framework. BJGP,
2007; 57: 441-448
10. McLean G, Sutton M, Guthrie B. Deprivation and quality of primary care
services: evidence for persistence of the inverse care law from the UK
Quality and Outcomes Framework. J Epi and Comm Health, 2006; 60: 917-
922

21. Professor Mike Pringle, Valencia, 24th June 2010
11. Doran T, Fullwood C, Kontopantelis E, Reeves D. Effect of financial
incentives on inequalities in the delivery of primary clinical care in England:
analysis of clinical activity indicators in the quality and outcomes framework.
The Lancet, 2008; 372: 728-736
12. Mangin D, Toop L. The Quality and Outcomes Framework: what have you
done to yourselves? BJGP, 2007; 57: 435-437
13. Lester H, Sharp D, Hobbs F, Lakhani M. The Quality and Outcomes
Framework of the GMC Contract: a quiet evolution for 2006 BJGP, 2006;
56: 244-246
14. Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance
contract: further evidence from the quality and outcomes framework.
University of York, 2007
15. Roland M. Linking physicians’ pay to the quality of care – a major
experiment in the United Kingdom. NEJM, 2004; 351: 1448-1454
16. Downing A, Rudge G, Cheng Y, Tu Y-K, Keen J, Gilthorpe M. Do the UK
government’s new Quality and Outcomes Framework (QoF) scores
adequately measure primary care performance? BMC Health Services
Research, 2007; 7: 166

22. Professor Mike Pringle, Valencia, 24th June 2010

23. Professor Mike Pringle, Valencia, 24th June 2010
THE IMPACT OF THE QUALITY AND
OUTCOMES FRAMEWORK
Professor Mike Pringle
Professor of General Practice
University of Nottingham