QOF Plus Year 1 - Imperial College London

Effect of measurement on health inequalityMant (2008) comments that “in everyday clinical practice, variability in usual care matters mostat the tail-end of the distribution where poor care can lead to adverse outcomes includingavoidable death.” Evidence from epidemiological studies suggest that while effective regularmechanisms for dealing with poor care are essential, a more effective approach is to developstrategies for raising average performance, and therefore shifting the whole distribution (Rose etal., 1990). An example of this is the introduction of cervical smear targets for UK general practicesin 1990. The highest targets were achieved rapidly by practices in affluent areas, and this resultedin an initial widening of the health inequality gap. However, practices in more deprived areascaught up over the next few years, thereby reducing inequality (Baker et al., 2003; Middleton etal., 2003). This phenomenon has been termed the inverse equity hypothesis (Victora et al., 2000).This hypothesis predicts that the benefits of new public health interventions are initiallyexperienced by the wealthier sector of the population and later by the poor, increasing theinequity ratio. However, once the poor have experienced benefits and a ceiling effect is reachedin the richer population, the inequity ratio which initially increases, then decreases.Although the Quality and Outcomes Framework was not designed to tackle health inequalities(Roland, 2004), there is evidence of the inverse equity hypothesis being relevant to QOF. Data isnow emerging which suggests that from a longer term perspective, more equitable healthcare isbeing generated following the introduction of QOF (Lester, 2008). Ashworth et al. (2008) assessedthe effects of social deprivation on levels of BP monitoring and control using data from over 97%of practices in England over the first three years of the QOF. They found that:“Since the reporting of performance indicators for primary care and the incorporation ofpay for performance in 2004, blood pressure monitoring and control have improvedsubstantially. Improvements in achievement have been accompanied by the neardisappearance of the achievement gap between least and most deprived areas.”Doran et al. (2008) looked at overall achievement in 48 of the clinical indicators in QOF and foundthat median achievement score increased across the board, with the gap in median achievementbetween practices in the most and least deprived areas reducing considerably.The evidence suggests that “low scoring practices in deprived areas also seem just as able toimprove the quality of their care (as measured by the Framework) as low scoring practices inmore affluent areas” (Lester, 2008). Lester (2008) further comments that:“Overall, the financial incentives seem to have reached areas of high need relativelyeffectively for most targets. An important subsidiary message is the need to take a longterm view when interpreting the effects of quality measures on health inequalities.”However, there remains concern that QOF may not encourage practices in reaching the morechallenging, hard-to-reach patients, as practices do not receive further incentives once they haveachieved the 90% upper threshold for payment (National Audit Office, 2008). This meanspractices can receive maximum points and payment for every clinical indicator before all eligiblepatients receive indicated care. Fleetcroft et al. (2008) comment that this can result in an‘incentive ceiling effect’ with associated reductions in health gains, and state that “there may beno rationale for maximum target thresholds to be set below 100% as there are comprehensivereasons for exception reporting any patient who would not theoretically benefit from theindicated care”. Setting and rewarding achievement of higher thresholds for selected existing4