General practice in the United Kingdom has the largest healthcare pay for performance programme in the world - the quality and outcomes framework (QOF). Practices earn points for the services they provide and these points attract financial resources into the practice.
Professor Bruce Guthrie and colleagues discuss the effectiveness of the system in relation to the management of cardiovascular disease and show how practices can earn many points and extra payments without necessarily reducing its risk.
For example, a practice could receive nine points (each worth about £125) for generating a list of patients with high blood pressure. An extra 30 points would be earned if 90% or more of such patients have a record of risk factors (blood pressure and smoking history) in their notes, and 56 more points would be earned if 70% or more of such patients have a record of blood pressure lowered to below specific target values.
Overall, 15% of payments, worth an estimated £200m across the approximate 11,000 general practices in the UK, arise from measuring cardiovascular risk factors (such as blood pressure and cholesterol) and recording whether they are below specified values.
They reason that it's time to incorporate treatment information into quality indicators, since it is the treatment of risk factors that reduces risk, not their measurement.
Meeting current targets for cardiovascular disease does not guarantee good management, they warn. Treatment information would clearly identify opportunities for intervention and improved patient care.
These views are supported by Consultant Cardiologist, David Wald, in an accompanying editorial. He believes that the treatment and prevention of cardiovascular disease is becoming a series of isolated tasks predicated on financial rather than clinical value, and argues that many of the QOF measurements relating to cardiovascular disease achieve little.
The QOF has been useful in drawing attention to the importance of the treatment and prevention of cardiovascular disease, but not how best to do so, he says.
He suggests simplifying the system so that payments are directly linked to treatment and prevention rather than the process, while protecting the independent professional status of doctors in the UK.