Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract

BACKGROUND: The Quality and Outcomes Framework (QOF) of the 2004 UK General Medical Services (GMS) contract links up to 20% of practice income to performance measured against 146 quality indicators. AIM: To examine the distribution of workload and payment in the clinical domains of the QOF, and to compare payment based on true prevalence to the implemented system applying an adjusted prevalence factor. We aimed also to assess the performance of the implemented payment system against its three stated objectives: to reduce variation in payment compared to a system based on true prevalence, to fairly link reward to workload, and finally, to help tackle health inequalities. DESIGN OF STUDY: Retrospective analysis of publicly available QOF data. SETTING: Nine hundred and three GMS general practices in Scotland. METHOD: Comparison of payment under the implemented Adjusted Disease Prevalence Factor, and under an alternative True Disease Prevalence Factor. RESULTS: Variation in total clinical QOF payment per 1000 patients registered is significantly reduced compared to a payment system based on true prevalence. Payment is poorly related to workload in terms of the number of patients on the disease register, with up to 44 fold variation in payment per patient on the disease register for practices delivering the same quality of care. Practices serving deprived populations are systematically penalized under the implemented payment system, compared to one based on true prevalence. CONCLUSIONS: The implemented adjustment for prevalence succeeds in its aim of reducing variation in practice income, but at the cost of making the relationship between workload and reward highly inequitable and perpetuating the inverse care law.     

Practice size and quality attainment under the new GMS contract: a cross-sectional analysis

BACKGROUND: The Quality and Outcomes Framework (QOF) of the new General Medical Services contract, for the first time, incentivises certain areas of general practice workload over others. The ability of practices to deliver high quality care may be related to the size of the practice itself. AIM: To explore the relationship between practice size and points attained in the QOF. DESIGN OF STUDY: Cross-sectional analyses of routinely available data. SETTING: Urban general practice in mainland Scotland. METHOD: QOF points and disease prevalence were obtained for all urban general practices in Scotland (n = 638) and linked to data on the practice, GP and patient population. The relationship between QOF point attainment, disease prevalence and practice size was examined using univariate statistical analyses. RESULTS: Smaller practices were more likely to be located in areas of socioeconomic deprivation; had patients with poorer health; and were less likely to participate in voluntary practice-based quality schemes. Overall, smaller practices received fewer QOF points compared to larger practices (P = 0.003), due to lower point attainment in the organisational domain (P = 0.002). There were no differences across practice size in the other domains of the QOF, including clinical care. Smaller practices reported higher levels of chronic obstructive pulmonary disease (COPD) and mental health conditions and lower levels of asthma, epilepsy and hypothyroidism. There was no difference in the reported prevalence of hypertension or coronary heart disease (CHD) across practices, in contrast to CHD mortality for patients aged under 70 years, where the mortality rate was 40% greater for single-handed practices compared with large practices. CONCLUSIONS: Although smaller practices obtained fewer points than larger practices under the QOF, this was due to lower scores in the organisational domain of the contract rather than to lower scores for clinical care. Single-handed practices, in common with larger practices serving more deprived populations, reported lower than expected CHD prevalence in their practice populations. Our results suggest that smaller practices continue to provide clinical care of comparable quality to larger practices but that they may need increased resources or support, particularly in the organisational domain, to address unmet need or more demanding QOF criteria.     

Diabetes care and the new GMS contract: the evidence for a whole county

The aim of this study was to assess the impact of the Quality and Outcomes Framework (QOF) of the new GP contract on diabetes care in Shropshire, which has a total population of approximately 460 000. The mean percentage of patients achieving each of the quality indicators in each practice in Shropshire, before and after the implementation of the QOF was calculated. All 16 867 patients with diabetes from all 66 Shropshire practices were included. There were significant improvements in the percentage of patients achieving targets for all quality indicators between April 2004 to March 2006 (P<0.001).     

Respiratory medicine.

The General Medical Services (GMS) contract has focused the attention of United Kingdom (UK) general practitioners (GPs) on the provision of high quality routine care for patients with chronic disease. The quality markers defined by the contract endorse the need for objective diagnosis and structured care recommended by the British Thoracic Society/Scottish Intercollegiate Guideline Network (BTS-SIGN) guideline for the management of asthma and the National Institute for Clinical Excellence (NICE) guideline on the management of chronic obstructive pulmonary disease (COPD). In this paper the key recommendations of these guidelines and their implementation in the pragmatic world of general practice are discussed, with specific focus on diagnosis, monitoring, management, self-management and delivery of care.     

Management in general practice: the challenge of the new General Medical Services contract.

BACKGROUND: Managers in general practice perform a variety of roles, from purely administrative to higher-level strategic planning. There has been little research investigating in detail how they perform these roles and the problems that they encounter. The new General Medical Services (GMS) contract contains new management challenges and it is not clear how practices will meet these. AIM: To improve understanding of the roles performed by managers in general practice and to consider the implications of this for the implementation of the new GMS contract. Design of study: In-depth qualitative case studies covering the period before and immediately after the vote in favour of the new GMS contract. SETTING: Three general practices in England, chosen using purposeful sampling. METHOD: Semi-structured interviews with all clinical and managerial personnel in each practice, participant and non-participant observation, and examination of documents. RESULTS: Understanding about what constitutes the legitimate role of managers in general practice varies both within and between practices. Those practices in the study that employed a manager to work at a strategic level with input into the direction of the organisation demonstrated significant problems with this in practice. These included lack of clarity about what the legitimate role of the manager involved, problems relating to the authority of managers in the context of a partnership, and lack of time available to them to do higher-level work. In addition, general practitioners (GPs) were not confident about their ability to manage their managers' performance. CONCLUSION: The new GMS contract will place significant demands on practice management. These results suggest that it cannot be assumed that simply employing a manager with high-level skills will enable these demands to be met; there must first be clarity about what the manager should be doing, and attention must be directed at questions about the legitimacy enjoyed by such a manager, the limits of his or her authority, and the management of performance in this role.     

The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework

BACKGROUND: The existence of health inequalities between least and most socially deprived areas is now well established. AIM: To use Quality and Outcomes Framework (QOF) indicators to explore the characteristics of primary care in deprived communities. DESIGN OF STUDY: Two-year study. SETTING: Primary care in England. METHOD: QOF data were obtained for each practice in England in 2004-2005 and 2005-2006 and linked with census derived social deprivation data (Index of Multiple Deprivation scores 2004), national urbanicity scores and a database of practice characteristics. Data were available for 8480 practices in 2004-2005 and 8264 practices in 2005-2006. Comparisons were made between practices in the least and most deprived quintiles. RESULTS: The difference in mean total QOF score between practices in least and most deprived quintiles was 64.5 points in 2004-2005 (mean score, all practices, 959.9) and 30.4 in 2005-2006 (mean, 1012.6). In 2005-2006, the QOF indicators displaying the largest differences between least and most deprived quintiles were: recall of patients not attending appointments for injectable neuroleptics (79 versus 58%, respectively), practices opening > or =45 hours/week (90 versus 74%), practices conducting > or = 12 significant event audits in previous 3 years (93 versus 81%), proportion of epileptics who were seizure free > or = 12 months (77 versus 65%) and proportion of patients taking lithium with serum lithium within therapeutic range (90 versus 78%). Geographical differences were less in group and training practices. CONCLUSIONS: Overall differences between primary care quality indicators in deprived and prosperous communities were small. However, shortfalls in specific indicators, both clinical and non-clinical, suggest that focused interventions could be applied to improve the quality of primary care in deprived areas.     

A retrospective review of significant events reported in one district in 2004-2005.

BACKGROUND: Patient safety is a key issue in primary care. Significant event analysis (SEA) is a long established method of improving safety. In 2004, SEA was introduced as part of the Quality and Outcomes Framework (QOF) of the new general medical services (GMS) contract. AIM: To review SEAs submitted for the QOF by general practices for a primary care trust (PCT) in 2004-2005. DESIGN OF STUDY: A retrospective review of SEAs. SETTING: St Helens PCT, Merseyside, North West England, UK (185 000 patients), now part of Halton and St Helens PCT. METHOD: Three hundred and thirty-seven QOF-reported SEAs were reviewed from 32 (91%) of a total of 35 St Helens PCT practices (mean 10.5, range 4-17). RESULTS: Practices identified learning points in 89% of SEAs. Twenty-two of 32 (69%) practices successfully performed SEA and required no further support. Four practices identified learning points but needed further facilitation in implementing change or actions arising from SEA. Six practices had significant difficulties with SEA processes and were referred for extra SEA training locally. Ninety (26.7%) of all significant events were classified as patient-safety incidents. Of these, 22 (6.5%) were 'serious or life threatening' and 67 (19.9%) were 'potentially serious'. Ninety-six (28.5%) of the significant events related to medicines management issues; and 63 (18.7%) had key learning points for partnership organisations. Main outcome measures were review of SEA process as a team learning event; QOF significant event criteria; National Patient Safety Agency classification of significant events, and category of patient-safety incidents. CONCLUSION: SEA in general practice is a valuable clinical governance and educational tool with potential patient safety benefits. Most practices performed SEA successfully but there were performance concerns and patient-safety issues were highlighted. This review emphasises the need for primary care organisations to be able to analyse and share SEAs effectively.     

Understanding general practice: a conceptual framework developed from case studies in the UK NHS

BACKGROUND: General practice in the UK is undergoing a period of rapid and profound change. Traditionally, research into the effects of change on general practice has tended to regard GPs as individuals or as members of a professional group. To understand the impact of change, general practices should also be considered as organisations. AIM: To use the organisational studies literature to build a conceptual framework of general practice organisations, and to test and develop this empirically using case studies of change in practice. This study used the implementation of National Service Frameworks (NSFs) and the new General Medical Services (GMS) contract as incidents of change. DESIGN OF STUDY: In-depth, qualitative case studies. The design was iterative: each case study was followed by a review of the theoretical ideas. The final conceptual framework was the result of the dynamic interplay between theory and empirical evidence. SETTING: Five general practices in England, selected using purposeful sampling. METHOD: Semi-structured interviews with all clinical and managerial personnel in each practice, participant and nonparticipant observation, and examination of documents. RESULTS: A conceptual framework was developed that can be used to understand how and why practices respond to change. This framework enabled understanding of observed reactions to the introduction of NSFs and the new GMS contract. Important factors for generating responses to change included the story that the practice members told about their practice, beliefs about what counted as legitimate work, the role played by the manager, and previous experiences of change. CONCLUSION: Viewing general practices as small organisations has generated insights into factors that influence responses to change. Change tends to occur from the bottom up and is determined by beliefs about organisational reality. The conceptual framework suggests some questions that can be asked of practices to explain this internal reality.     

Quality measurement of care for people with type 2 diabetes in Tayside, Scotland: implications for the new UK general practice contract.

BACKGROUND: The new United Kingdom general practice contract proposes that up to a third of general practitioners' income will come from achieving quality targets. AIM: To examine selected quality markers in terms of their robustness to case-mix variation and chance effects, and in the attribution of quality to practices. STUDY DESIGN AND METHODS: Data were extracted from a population-based diabetes clinical information system in Tayside, Scotland, for patients with type 2 diabetes registered in 67 practices with complete ascertainment. RESULTS: Most practices would have received relatively high levels of payment for the process measures examined. Outcome measures appeared more challenging. Case-mix adjustment for age, sex, and postcode-assigned deprivation altered measured performance by up to 7%, but payment by up to 14%. Despite no strong evidence of any real difference in quality, chance effects meant that there was greater apparent variability for smaller practices from year to year. Hospital attendance was common, but highly variable between practices. CONCLUSION: Case-mix adjustment to allow fairer comparison is routine in national performance indicators, and ignoring it risks making the new contract quality framework inequitable. Because of chance effects, smaller practices may have greater year-to-year variability in income. Reflecting National Health Service structure, the new contract provides no incentives for integrated care and offers a perverse incentive to refer more patients to hospital. There are trade-offs between the validity of measures, and the cost and bureaucracy of collecting data. The planned evaluation of the new contrast should examine the effectiveness and equity of the quality framework, and rapidly act on deficiencies found.     

Higher professional education for general medical practitioners: key informant interviews and focus group findings.

BACKGROUND: If higher professional education (HPE) for general practitioners (GPs) is to be implemented, then key stakeholders will need to be supportive. AIM: To investigate stakeholders' beliefs about the concept of HPE, its funding, and relationships to education and care. METHOD: Interviews were conducted using a topic guide with a health authority (HA) representative, the Local Medical Committee Chair, the Medical Audit Advisory Group Chair, a GP tutor from each of the six health authorities in the old South West region, and a senior member of the three academic GP departments and the two Royal College of General Practitioners faculties in the region. Focus groups were held with GP registrars on both vocational training schemes (VTSs) and on the one HPE course in the region. These were recorded, transcribed verbatim, and analysed for emergent themes that were triangulated with the ideas expressed in the focus groups; the same topic guide was used for both. RESULTS: Of 29 key informants, 24 were interviewed. Six focus groups were held (the one HPE group and five out of the nine VTSs), after which no new ideas emerged. There is a transition period, after becoming a new principal (NP) and before becoming a fully competent independent GP, during which NPs need support. Benefits would include receiving peer support to reduce stress during the transition, enhanced non-clinical competencies, becoming a better skilled GP, avoiding the negative personal impact of a career as a GP, and helping recruitment. To improve patient care there must be a link between education and service provision. Funding is the major consideration in setting HPE; mixed funding is best coming from top-sliced General Medical Services (GMS), the HA, and regional educational funds. Barriers might include NPs' practice workload, their enthusiasm, and their partners' attitudes. The other key is a local enthusiast to initiate a course and coordinate the 'players'. The curriculum would be principally non-clinical and should be agreed by learners and the course tutor together, taking advice from various interested parties. CONCLUSION: There is a need for HPE for new NPs. It will require funding external to individual practices or NPs and a local enthusiast. Top-slicing of GMS funds is one source of funding, with additional funds from regional education and HAs. HPE must be related to service provision, to NP needs, and to vocational training.     

The "silver-haired" general medical services patient. Clinical activity of the non-means tested over-70's during their first six months

The objective was to examine the impact on general practice clinical activity of the granting of medical cards to all patients over 70 years of age on 01.07.01 under the General Medical Services (GMS) scheme. Retrospective case-control study. Chart review of 50 "new GMS" patients who received medical cards on 01.07.01 compared with 50 "old GMS" patients with means tested medical cards on this date. Single-handed mixed urban/rural general practice in Ireland. 1. Attendance rates. 2. Health status as measured by total number of chronic diseases, prevalence of hypertension, diabetes and cardiovascular disease. 3. Quality of preventive care comprising influenza and pneumococcal vaccine uptake rates; hypertension control; hyperlipidaemia control; level of screening activity for hypertension, diabetes, hyperlipidaemia, prostate specific antigen (among men) and smoking behaviour. Comparisons were made both before and after free GMS care for all between the "old GMS" and "new GMS" patient groups. Behaviour of the "new GMS" group was also compared, both before and after GMS eligibility. Prior to universal eligbility "old GMS" patients attended more often (p=0.0002), had more documented chronic illness (p=0.0002), consumed more medications (p=0.0002), were more likely to be diagnosed hypertensive (p=0.0336) and to have prostate specific antigen (PSA) measurement (men only) (p=0.048) than "new GMS" patients. Within the first 6 months of free GMS care for all, the "new GMS" patients attended significantly more often than before with the percentage of high consulters increasing from 24% to 52% (p=0.0039), took more medications (from 1.72 to 2.2), showed improvement in all quality of care parameters (with the exception of PSA screening which remained static) and had improved attendance for influenza 40% to 62% (p=0.0277) and pneumococcal vaccines 2% to 26% (p=0.00054). More "new GMS" patients were diagnosed as hypertensive (24% to 38%) to a prevalence no longer significantly different from the "old GMS" group. Free general practice care has impacted positively on this "new GMS" patient group of over 70's. Our data suggests that the low consultation rate of this group when fee paying may have resulted in less exposure to practice screening activities. The apparent better health status among this group may in fact be a fa?ade masking undiagnosed chronic disease, notably hypertension.     

Cost-effectiveness of asthma control: an economic appraisal of the GOAL study

BACKGROUND: The Gaining Optimal Asthma ControL (GOAL) study has shown the superiority of a combination of salmeterol/fluticasone propionate (SFC) compared with fluticasone propionate alone (FP) in terms of improving guideline defined asthma control. METHODS: Clinical and economic data were taken from the GOAL study, supplemented with data on health related quality of life, in order to estimate the cost per quality adjusted life year (QALY) results for each of three strata (previously corticosteroid-free, low- and moderate-dose corticosteroid users). A series of statistical models of trial outcomes was used to construct cost effectiveness estimates across the strata of the multinational GOAL study including adjustment to the UK experience. Uncertainty was handled using the non-parametric bootstrap. Cost-effectiveness was compared with other treatments for chronic conditions. RESULT: Salmeterol/fluticasone propionate improved the proportion of patients achieving totally and well-controlled weeks resulting in a similar QALY gain across the three strata of GOAL. Additional costs of treatment were greatest in stratum 1 and least in stratum 3, with some of the costs offset by reduced health care resource use. Cost-effectiveness by stratum was 7600 pound (95% CI: 4800-10,700 pound) per QALY gained for stratum 3; 11,000 pound (8600-14,600 pound) per QALY gained for stratum 2; and 13,700 pound (11,000-18,300 pound) per QALY gained for stratum 1. CONCLUSION: The GOAL study previously demonstrated the improvement in total control associated with the use of SFC compared with FP alone. This study suggests that this improvement in control is associated with cost-per-QALY figures that compare favourably with other uses of scarce health care resources.     

Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data

Background

In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.

Aim

To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.

Design of the study

Cross-sectional analysis of routine data.

Setting

English general practice in 2005/2006.

Method

QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.

Results

A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA_1C] ≤7.4%, HbA_1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).

Conclusion

Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.     

Measuring patient satisfaction for the Quality and Outcomes Framework.

The general medical services (GMS) contract Quality and Outcomes Framework (QOF) awards up to 70 points for measuring patient satisfaction with either the Improving Practices Questionnaire (IPQ) or the General Practice Assessment Questionnaire (GPAQ). The usefulness of data collected depends crucially on the validity and reliability of the measurement instrument. The literature was reviewed to assess the validity and reliability of these questionnaires. The literature was searched for peer-review publications that assessed the reliability and validity of the IPQ and GPAQ, using online literature databases and hand-searching of references up to June 2006. One paper claimed to assess the validity and reliability of the IPQ. No paper reported the reliability and validity of the GPAQ, but three papers assessed an earlier version (the GPAS). No published evidence could be found that the IPQ, GPAQ, or GPAS have been validated against external criteria. The GPAS was found to have acceptable reliability and test-retest reliability. Neither of the instruments mandated by the GMS contract has been formally assessed for reliability: their reproducibility remains unknown. The validation of the two questionnaires approved by the QOF to assess patient satisfaction with general practice appears to be suboptimal. It is recommended that future patient experience surveys are piloted for validity and reliability before being implemented widely.     

The Public Health Impact score: a new measure of public health effectiveness for general practices in England

Background

Health policy in the UK is increasingly focused on the measurement of outcomes rather than structures and processes of health care.

Aim

To develop a measure of the effectiveness of primary care in terms of population health outcomes.

Design and setting

A cross-sectional study of general practices in England.

Method

Twenty clinical quality of care indicators for which there was evidence of mortality reduction were identified from the national Quality and Outcomes Framework (QOF) pay-for-performance scheme. The number of lives saved by 8136 English practices (97.97% of all practices) in 2009/2010 was estimated, based on their performance on these measures, and a public health impact measure, the PHI score, was constructed. Multilevel regression models were used to identify practice and population predictors of PHI scores.

Results

The mean estimated PHI score was 258.9 (standard deviation [SD] = 73.3) lives saved per 100 000 registered patients, per annum. This represents 75.7% of the maximum potential PHI score of 340.9 (SD = 91.8). PHI and QOF scores were weakly correlated (Pearson r = 0.28). The most powerful predictors of PHI score were the prevalence of the relevant clinical conditions (β = 0.77) and the proportion of patients aged ≥65 years (β = 0.22). General practices that were less successful at achieving their maximum potential PHI score were those with a lower prevalence of relevant conditions (β = 0.29), larger list sizes (β = −0.16), greater area deprivation (β = −0.15), and a larger proportion of patients aged ≥65 years (β = −0.13).

Conclusion

The PHI score is a potential alternative metric of practice performance, measuring the estimated mortality reduction in the registered population. Rewards under the QOF pay-for-performance scheme are not closely aligned to the public health impact of practices.     

Lessons from the London Initiative Zone Educational Incentives funding: associations between practice characteristics, funding, and courses undertaken.

BACKGROUND: Following the Tomlinson report of 1992, London Initiative Zone Educational Incentives (LIZEI) funding was introduced for a three-year period to improve recruitment, retention, and educational opportunities for general practitioners working within inner London. AIM: To test the hypothesis that general practices that show evidence of good organisation achieved better access to LIZEI funding than less organised practices. METHOD: Observational practice-based study involving all 164 general practices in EAst London and the City Health Authority during the first two years of the scheme, April 1995 to March 1997. RESULTS: Univariate analysis showed that higher levels of LIZEI funding were associated with practices where there was evidence of good organisation, including higher targets for cervical cytology screening and immunisation rates for under two-year-olds, better asthma prescribing, and training status. Using ten practice and population explanatory variables, multiple regression models were developed for fundholding and non-fundholding practices. Among non-fundholding practices, the asthma prescribing ratio was the variable with the greatest predictive value, explaining 14.7% of the variation in LIZEI funding between practices. Strong positive associations existed between taking further degrees and diplomas, practice size, training, and non-fundholding status. CONCLUSION: Larger practices, training practices, and those that demonstrated aspects of good practice organisation gained more LIZEI funding: an example of the 'inverse funding law'. Practices within a multifund, based in the Newham locality, gained LIZEI funding regardless of practice organisation. Networks of practices, and, potentially, primary care groups, have a role in equalising the opportunities for education and development between practices in east London.     

Practice costs of implementing guidelines for asthma and angina: findings from a randomised controlled trial.

We collected information about the costs of three interventions (dissemination of full guidelines or prioritised review criteria or criteria plus feedback) to improve care of adults with stable angina or asthma within the context of a randomised controlled trial. The cost of criteria with feedback was pound180 per practice compared to pound9.60-31.45 for the other interventions. Total mean costs borne by practices varied between pound838 and pound2127 per practice depending upon disease and intervention type.     

Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population-database analysis

Background

Influenza immunisation is recommended for all people aged ≥65 years and younger people with particular chronic diseases. The Quality and Outcomes Framework (QOF) has provided new financial incentives for influenza immunisation since 2004.

Aim

To determine the impact of the 2004 UK General Medical Services contract on the overall uptake of, and socioeconomic inequalities associated with, influenza immunisation.

Design and setting

Retrospective general-practice population database analysis in 15 general practices in Scotland, UK.

Method

Changes in influenza-immunisation uptake for those in at-risk groups between 2003–2004 and 2006–2007 were measured, and variation in uptake examined using multilevel modelling.

Results

Uptake rose from 67.9% in 2003–2004 to 71.4% in 2006–2007. The largest increases were seen in those aged <65 years with chronic disease, with uptake rising from 49.6% to 58.4%, but rates remained considerably lower than in those aged ≥65 years. Differences between practices narrowed (median odds ratio [OR] for two patients randomly selected from different practices: 2.13 (95% confidence interval [CI] = 2.00 to 2.26) in 2003–2004 versus 1.44 (95% CI = 1.40 to 1.49) in 2006–2007. However, inequalities in uptake by patient socioeconomic status did not change: adjusted OR for most deprived versus most affluent was 0.75 (95% CI = 0.70 to 0.80) in 2003–2004 versus 0.72 (95% CI = 0.68 to 0.76) in 2006–2007.

Conclusion

Overall uptake rose significantly and differences between practices narrowed considerably. However, socioeconomic and age inequalities in influenza immunisation persisted in the first 3 years of the QOF. This contrasts with other ecological analyses, which have concluded that the QOF has reduced inequalities. The impact of financial incentives on inequalities is likely to vary, and some kinds of care may require more targeted improvement activity and support.     

Patients' views of pay for performance in primary care: a qualitative study

Background

Many countries use pay-for-performance schemes to reward family practices financially for achieving quality indicators. The views of patients on pay for performance remain largely unexplored.

Aim

To gain the views of family practice patients on the United Kingdom pay-for-performance Quality and Outcomes Framework (QOF).

Design and setting

Interviews with 52 patients were conducted in 15 family practices across England. All patients had at least one long-term condition that had been diagnosed before the introduction of the QOF in 2004.

Method

Semi-structured interviews analysed using open explorative thematic coding.

Results

Few patients had heard of the QOF or had noticed changes to the structure or process of their care. However, where they were noted, changes to consultations such as increased use of computers and health checks initiated by the GP or practice nurse were seen as good practice. The majority of patients were surprised to hear their practice received bonuses for doing ‘simple things’. Some patients also raised concerns over potential unintended consequences of pay-for-performance frameworks, such as a reduced focus on non-incentivised areas.

Conclusion

This study adds a unique patient perspective to the debate around the impact of pay-for-performance schemes and consequences on patient care. Patients'' views, experiences, and concerns about pay for performance mostly chime with previously described opinions of primary care staff. Patient surprise and concern around incentivising basic processes of care shows how patient views are vital when monitoring and evaluating a scheme that is designed to improve patient care.