Axing QOF payments in Scotland linked to slump in GP checks

They found that, three years on, there were "statistically significant reductions" in documented care for 10 measures compared to England.

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These included a 23 per cent drop in the recording of diabetic foot screening and a reduction of nearly 17% in blood pressure monitoring in patients with a history of stroke.

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The biggest fall was in mental health care planning - where patients with conditions such as schizophrenia or bipolar disorder - have a comprehensive care plan documented in their medical record. By 2019, this was 40% lower in Scotland than England.

There was no significant change, however, for treatment indicators - such as flu vaccinations.

The findings are published today in the British Medical Journal (BMJ). 

The authors stress that the findings do not necessarily mean that patient care or outcomes deteriorated, although they said further work is needed to investigate the impact of blood pressure readings, for example, on hospital heart attack admissions among patients with hypertension.

Dr Daniel Morales, an expert in population health at Dundee University, said: “Whilst changes in performance appear to have occurred after QOF withdrawal in Scotland it is difficult to distinguish whether this was related to care not being recorded as opposed to not being delivered.

“It's also important to recognise that we know that although QOF did lead to some improvement in reported quality of care when introduced, it also risked 'crowding out', with less attention on other aspects of care which were not part of pay-for-performance.

"However, we were not able to examine whether abolishing QOF reduced these unintended effects of pay-for-performance."

There was no statistically significant reduction in the delivery of flu vaccines to vulnerable groups in Scotland compared to England, although more recently in Scotland responsibility for vaccinations has been transferred to health boards (Image: PA)

The Quality and Outcomes Framework (QOF) system was introduced UK-wide by the 2004 GP contract.

Its aim was to encourage better clinical management of chronic diseases by rewarding GP practices with payments in return for meeting performance targets, such as carrying out blood pressure checks on a certain percentage of patients with a history of coronary heart disease or screening a certain proportion of diabetics for signs of foot ulcers.

When it was first rolled out - with an original checklist of 66 indicators - it accounted for as much as 20% of general practices’ remuneration.

As time went on, however, it was criticised as a "tick-box exercise" that was burdening GP time while adversely affecting the management of conditions which did not come with financial incentives.

Studies found no improvements in mortality, and modelling suggested it was not cost-effective for the NHS.

READ MORE: 'It's falling apart' - Scots GPs on the future of general practice 

Against this backdrop, Scotland axed QOF in April 2016 and added the relevant funds into the core GP budget.

The move was backed by the BMA and the Royal College of GPs in Scotland. England is also widely expected to ditch QOF in the near future.

Today's study is the first to compare subsequent performance between the two nations from 2016 to 2019, based on documented care.

Excluding trainees, Scotland's GP workforce by headcount has increased from 4,387 in 2016 to 4,515 in 2022 (Image: Public Health Scotland)

Patricia Moultrie, deputy chair of the BMA's Scottish GP Committee, said that the results should be interpreted with "considerable caution".

She added: "The method of recording important measurements such as blood pressure in patients records changed after the move away from QOF so changes within practice processes will have affected this analysis.

"In addition to that GPs now work with a wider team responsible for delivering care in the community and information flow from HSCP and board-delivered services requires further development as does assimilation of an increasing move towards patients undertaking, for example, [blood pressure] measurements at home.

"So there are a number of clear reasons why this study cannot in itself distinguish between a change in recording as opposed to a change in quality."

READ MORE: Record number of Glasgow GP surgeries closed to new patients 

However, the researchers noted that while QOF was associated with "relatively small" improvements in the quality of care, there was evidence that it "narrowed the quality gap between practices serving socio-economically deprived versus affluent practices".

They added: "Research is needed to examine the impact on variation between practices and inequities of withdrawing incentives."

Writing in a linked editorial in the BMJ, Katherine Checkland - a professor of primary care at Manchester University who was not involved in the study - said the benefits of QOF had been "modest at best".

She said: "While the drop in recorded performance may be concerning,the lack of evidence for long term effectiveness and cost effective of pay for performance in primary care suggests that there is as yet no need to panic."

Dr Chris Williams, joint chair of RCGP Scotland, said the paper's findings "require careful and nuanced consideration". 

He added: “The single most impactful outcome for quality care in Scotland would be ensuring a fully staffed, funded and resourced general practice.”