Pay for Quality

KCE Reports 118 Pay for Quality 43
4.2.4 Description of P4Q interventions
4.2.4.1 United Kingdom
Primary care: Quality and Outcomes Framework (QOF)
British family practitioners derive their income from NHS patients. Almost all of the
citizens of the UK are registered with a family practitioner, and family practitioners have
registered lists of patients for whom they are responsible. Their work within the NHS is
governed by a national contract, known as the General Medical Services contract that is
negotiated between professional representatives of the British Medical Association and
the central government. This contract is revised at infrequent intervals; since the NHS
started in 1948, major contract revisions have been made only in 1966 and 1990 55 .
At the core of the general practitioners contract was the Quality and Outcomes
Framework (QOF), which links financial incentives to the quality of care that is provided
by practices. The contract for providing medical care and all quality payments relate to
the practice rather than to the individual physician. Under the 2004 contract,
responsibility moves from the individual family practitioner to the practice, which is a
group of, typically, one to six physicians. In 2004, the National Health Service
committed £1.8 billion ($3.2 billion) in additional funding over a period of three years
for a new pay for performance programme for family practitioners.
The quality-of-care payments make up approximately 20 percent of the government’s
total family practice budget.
These figures are gross numbers and therefore include the additional costs (e.g., for the
employment of nurses) that physicians may need to incur in order to deliver high
standards of care. The percentage increase in available resources for individual
physicians thus depends on the extent to which they have already invested in highquality
systems in their practices.
This programme was intended to increase family practitioners’ income by up to 25
percent, depending on their performance with respect to 146 quality indicators relating
to clinical care for 10 chronic diseases, organization of care, and patient experience.
1. Quality is measured against a set of clinical activity indicators relating to
aspects of care for several common chronic diseases, with practices
rewarded according to the proportion of eligible patients for whom each
target is achieved. Family practitioners earn more points if higher proportions
of these patients have undergone “process measures” and further points for
“intermediate outcomes” (i.e. management of these risk factors within certain
limits). Generally, more points are available for the intermediate outcomes
than for the process measures, which reflect the increased difficulty of
achieving these standards. The number of points that can be earned for each
indicator was determined partly by the academic advisory group and partly by
a formal scoring process undertaken by groups of family practitioners in
England and Scotland. The intention behind this process was to allocate
points on the basis of the workload required to provide care to the relevant
standard.
For the clinical indicators, practices claim points that generate payments
according to the proportion of patients for whom they achieve each target.
Points are awarded on a sliding scale within the payment range. For example,
for asthma indicator number 6, practices gain points for clinically reviewing at
least 25 percent of patients with asthma in the previous 15 months. The
maximum of 20 points is gained if at least 70 percent of patients with asthma
are reviewed.
For 2004–2005, payment was limited to £76 ($133) per point, adjusted for
the relative prevalence of the disease (payment is multiplied by the square
root of the prevalence of the disease among the patients served by the
practice and divided by the square root of the mean national prevalence of
the disease). A maximum of 1 050 points was available, which was equivalent