Is QOF bad for your heart?
QOF targets may be leading to harmful consequences for patient care. It’s time to change, write Laura Boyd and Dr Matt Kearney of UCLPartners.
Every three minutes someone, somewhere dies from a heart attack, stroke or other form of cardiovascular disease. We all know a family member, a friend or a colleague who has been affected, yet we know that these catastrophic illnesses are very preventable - not just through changes to lifestyle, but by treating high-risk conditions like high blood pressure and cholesterol.
In general practice, funding from the Quality and Outcomes Framework (QOF) enables us to deliver good clinical care and we work particularly hard towards the end of the financial year to ensure we achieve our quality targets. But is there a risk these targets are driving a major gap in care for our patients, with potentially harmful consequences?
Size of the Prize
Data from UCLPartners’ Size of the Prize, published every three months for each integrated care board, shows current achievement and what would be possible if blood pressure and cholesterol treatment was improved to reasonable ambition levels. Across England, blood pressure optimisation rates are currently 67 per cent of people with hypertension treated to target. If this was increased to 80 per cent, approximately 16,000 heart attacks and strokes would be prevented over three years. Similar numbers of cardiovascular events would be prevented if 95 per cent of people with cardiovascular disease were treated with lipid lowering therapy.
There are not many interventions that would deliver this level of population health impact
These are huge numbers. There are not many interventions that would deliver this level of population health impact with the accompanying reduction in demand for expensive health and social care.
Treatment gets worse ‘post-QOF’
The striking new finding in Size of the Prize is that blood pressure optimisation rates fell significantlyafter March 2023. Why does this happen? Because 31 March is the date when GP practice performance is measured for payment under QOF. Understandably, GP teams maximise their efforts to recall and review patients in the last three or four months of the year in order to achieve annual targets. With the constant capacity challenges in primary care, they then divert their attention to other priorities. The imperative is to have blood pressure (and other conditions) optimised at year end, with timing of patient reviews often determined by contractual rather than clinical priority.
…for at least six months ‘post QOF’, many thousands of people across England have dropped out of optimal therapy
This QOF effect may have serious unintended consequences for patients with hypertension. The data shows that for at least six months ‘post QOF’, many thousands of people across England have dropped out of optimal therapy. Some of these individuals – and potentially large numbers – will have a fatal or life-changing heart attack or stroke as a result. Evidence shows that even a six-week delay in blood pressure optimisation increases risk of an acute cardiovascular event or death.
It’s time to modernise QOF
Switching the QOF incentive from a once-a-year target achievement to a requirement for ongoing year-round case finding for patients whose care needs optimising, would drive improved outcomes. Regularly interrogating routine GP data, using tools like CVDACTION, will systematically identify patients with hypertension and other high-risk conditions who are on sub-optimal therapy, so that they can be prioritised for review and not wait until an arbitrary anniversary of their previous review.
It is time to shift away from reward for meeting one-off annual targets that do not reflect year-round care
QOF has supported quality improvement in England over the last 20 years, but it is time to recognise that we could do much better. The recently announced review of general practice incentives brings an opportunity to support primary care teams to do things differently for the benefit of our patients.
It is time to shift away from reward for meeting one-off annual targets that do not reflect year-round care. Using QOF to incentivise ongoing case finding and active optimisation of blood pressure and other high-risk conditions could prevent large numbers of heart attacks and strokes.
Laura Boyd is director of implementation at UCLPartners. Dr Matt Kearney is a GP and senior adviser to UCLPartners. You can connect with Laura and Matt on LinkedIn:
