Can the QOF help us realise the aims of the Five Year Forward View?

Problem

Improving care for people with long-term conditions is central to NHS policy. The Five Year Forward View prioritises integrated care, personalised care and self-care for these patients. It has been suggested that the Quality and Outcomes Framework (QOF), a pay-for-performance scheme in primary care that rewards practices for delivering effective interventions in the management of long-term conditions, does not encourage these broader elements of care, beyond simply delivery of specific interventions or biomedical outcomes.

Approach

We carried out a systematic review of evidence that the QOF has improved any aspect of quality of care or outcomes among patients with long-term conditions. We took a broad view of quality and outcomes, examining the effect of QOF on elements of care highlighted in the Five Year Forward View and patient experience, as well as physiological or biochemical measures of health, health service utilisation and mortality. We included quantitative studies published in peer-reviewed journals in English that examined the effect on any outcome of introducing QOF. We included uncontrolled studies if they used an interrupted time series approach.

Findings

We found two systematic reviews with search dates in 2012 and a further systematic review with a search date in 2015 that did not identify any further studies. We found five subsequent studies meeting our inclusion criteria. The systematic reviews concluded that the effect of QOF was uncertain. Four of the subsequent studies provided weak evidence that QOF was associated with a modest effect on slowing the rate of increase in emergency admission rates, a modest increase in consultation rates in severe mental illness, and modest improvements in limited aspects of the care of diabetes. Because all the studies were uncontrolled, we cannot be sure that any of these associations are causal. A further study found no evidence that QOF had improved mortality in the UK compared with other countries with no pay-for-performance in primary care. We found no evidence that QOF influences, positively or negatively, integration or coordination of care, holistic or personalised care, or self-care, or patients’ experience, quality of life or satisfaction.

Consequences

If it is to realise the aims of the Five Year Forward View, the NHS should consider more broadly what constitutes high quality primary care for people with long-term conditions, and consider monitoring performance on an alternative basis. This work also highlights that the QOF model of pay-for-performance may not be the most effective way of promoting better quality of care or better outcomes in primary care.