On Aug 10, the UK's National Institute for Health and
Clinical Excellence (NICE) published its fi rst menu of new
indicators for the Quality and Outcomes Framework
(QOF). The QOF, a voluntary pay-for-performance scheme
designed to reward UK general medical practices for
provision of high-quality care, started in April, 2004.
Incentives are paid on achievement of points for clinical
indicators, practice organisation, and patient experience,
and are devised to challenge practices to improve.
Although a voluntary scheme, the QOF provides roughly
15% of practice income and consequently most prac tices
participate. At �1�76 billion over budget in its fi rst 3 years,
critics have said that incentives are too easy to achieve.
Furthermore, the question of whether a focus on process
and crude data collection rather than individual ised
care improves patient outcomes is yet to be answered.
Concerns have been expressed that the system encourages
overtreatment, is abused through exception reporting,
and creates inequalities rather than tackling them. Of
greater concern is that care has not improved in areas not
included in the QOF, eg, some aspects of diabetes care.
Increased transparency of how indicators are set was
called for in the Darzi report, in June, 2008. Until now,
both negotiation of changes to QOF and assessment
of evidence have been done by the QOF expert panel.
Moreover, payments have not been weighted to
anticipated health benefi ts from achievement of
indicators. NICE, who took over management of review
and development of indicators in April, 2009, is expected
to ensure that the process is evidence-based, has more
local fl exibility, and swing the focus towards patient
outcomes and cost-eff ectiveness. Tougher targets are
also expected, which could aff ect practice income.
The role of NICE is to provide evidence-based
recommendations, but their participation is also a step
to wring more value for money out of a system that is
presently costing the NHS �1 billion per year and is yet
to prove it can strengthen general practice. General
practitioners will need to show that, irrespective of
incentives for surrogate endpoints, they can deliver
better evidence-based care to improve patient
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