Impact of removing indicators from the quality and outcomes framework: Retrospective study using individual patient data in England: Report to NHS England

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NHS England are currently conducting a review of the Quality and Outcomes Framework (QOF). One of the key areas for investigation is the potential impact of removing the incentives on the quality of care delivered in general practice.

There is little evidence on the impact of removing financial incentives and the available evidence is inconclusive. There has been limited national monitoring of the consequences of the indicators that have been removed from the QOF in England in recent years. We used a large patient level dataset to examine changes in achievement of indicators once they were removed from the QOF.

We used data from a national sample of 131 general practices in the Clinical Practice Research Datalink over the period 2006/7 to 2016/17. We focused on indicators in the coronary heart disease, chronic kidney disease, hypertension, mental health and hypothyroidism domains. We analysed how achievement of the indicators changed in response to changes in the design of the associated financial incentives and their removal from the QOF. We examined overall performance as well as performance stratified by sex, age group, presence of comorbidities (Charlson Comorbidity Index), area deprivation (Index of Multiple Deprivation), and frailty (Electronic Frailty Index).

We find that practices responded quickly to the changes in the design of the QOF indicators and to their complete removal. Across all of the indicators, there were substantial increases in the proportions of patients who did not have a required measurement during the financial year when the indicator was removed. In some cases, performance dropped to levels lower than was recorded before the indicator was introduced.

In general, we found that the changes in indicator achievement were similar for women and men and by age group. The youngest and oldest patients tended to have the lowest rates of achievement across the period. There were drops in achievement both for patients without comorbidities and for patient with comorbidities, though the decreases tended to be smaller for patients with comorbidities and for the patients with the highest levels of frailty. Patients in more deprived areas had lower levels of indicator achievement throughout the period. There was little evidence of differential effects of indicator removal by level of deprivation.

We also undertake additional analyses on how indicator removal affects wider aspects of care provision, such as consultation rates and prescriptions. There was little relationship between indicator removal and consultation rates. For hypertension, there was evidence that the intensity of prescribing was related to indicator introduction and removal.

Amongst the patients who achieved indicators in the year prior to the incentives being withdrawn, females, patients aged over 85 years, patients classified as ‘fit’ in terms of frailty, and patients without comorbidities were more likely to fail the indicator in the following year.
Original languageEnglish
Place of PublicationManchester
PublisherPolicy Research Unit in Commissioning and the Healthcare System Manchester Centre for Health Economics
Number of pages139
Publication statusPublished - 28 Jun 2018


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