Closed consultation

Role of incentive schemes in general practice

Updated 5 March 2024

Applies to England

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Ministerial foreword

General practice plays a central role in delivering accessible and comprehensive healthcare services to our population. Incentive schemes like the Quality and Outcomes Framework (QOF) and the Impact and Investment Fund (IIF) have been important in shaping and driving improvements in the delivery of these services.

Since its inception, QOF has helped us set and achieve ambitious targets, improve the management of long-term conditions, and enhance patient experience. IIF has played a crucial role in supporting primary care networks (PCNs) to deliver high-quality care to their population and in the delivery of the priority objectives articulated in the NHS Long Term Plan. I am incredibly grateful to general practitioners and their staff, who have performed highly against QOF and IIF targets in the face of increasing demands, complex medical cases and evolving patient expectations. 

As we navigate these pressures, and as the healthcare landscape evolves, we must ensure that any incentive schemes within primary care continue to serve the best interests of our patients. The current schemes need to adapt and respond to the changing needs of our population and the evolving priorities in healthcare, such as those outlined in the case for change and strategic framework for the major conditions strategy.

This public consultation is an invitation to all stakeholders - including healthcare professionals, patient groups and the wider public - to share their views and insights on the role of incentive schemes in general practice. Your input will be invaluable in helping us shape their future role in driving excellence and innovation in general practice.

We are committed to listening to your views, considering your recommendations, and making evidence-based decisions that prioritise the best interest of our patients and our healthcare system. Together, we will ensure that any future incentive schemes in primary care will continue to be effective tools in our mission to provide the highest standard of healthcare for all.

The Rt Hon Andrea Leadsom MP
Parliamentary Under Secretary of State for Public Health, Start for Life and Primary Care

Introduction

In England, general practices are incentivised through 2 main schemes, the:

  • Quality and Outcomes Framework (QOF)
  • Investment and Impact Fund (IIF)

These schemes aim to enhance healthcare delivery and patient outcomes by incentivising continuous improvement in clinical care and public health delivery. Practices that achieve the targets set in these schemes receive additional income to their core funding. 

Earlier this year, we made a commitment (see Changes to the GP contract in 2023 to 2024) to consult with the public and profession on the future of QOF. We have expanded the scope, so this consultation focuses on the role of both QOF and IIF.

Quality and Outcomes Framework

The Quality and Outcomes Framework scheme was established in 2004 as an optional framework that general practices can choose to participate in. The 2023 to 2024 scheme consists of 76 indicators, each with a specific target for achievement.

The majority of QOF indicators were suspended in 2020 to 2021 and 2021 to 2022 due to COVID-19 and, as we focus on recovering access, we have income protected some indicators in 2023 to 2024. 

Impact and Investment Fund

In 2019, with the introduction of primary care networks (PCNs), we implemented a similar scheme called the Investment and Impact Fund. Although it focuses on different indicators, it operates in a similar manner, providing additional income to PCNs that attain their targets. 

As with QOF, the majority of IIF indicators were suspended in 2020 to 2021 and 2021 to 2022 due to COVID-19, with 2022 to 2023 being the first year that IIF has been fully implemented. In 2023 to 2024, we reduced the number of indicators in IIF from 36 to 5, and re-targeted the funding to enable practices and PCNs to focus on improving patient experience of contacting their practice. 

Role of incentive schemes in general practice

Incentive schemes based on clinical indicators have been part of practice income for almost 20 years. This section seeks feedback on whether these schemes are working, and, if not, what the alternative mechanisms are that could encourage proactive care, outcomes and clinically led quality improvement.

Inclusion of incentive schemes in general practice income

We think that incentives are a valuable tool for effectively allocating resources towards priority clinical areas. Some studies demonstrate that the introduction of QOF resulted in enhanced quality of care, reduced variation and better patient outcomes. They also consistently demonstrate that incentives lead to increased levels of recorded activity. See:

Strong evidence from Scotland indicates that the removal of QOF indicators led to a sustained reduction in recorded quality of care. See:

However, we also recognise that QOF has limitations and can take focus away from non-incentivised areas of clinical care, slowing down rate of improvement in quality for other conditions. See:

Question

Do you agree or disagree that incentives like QOF and IIF should form part of the income for general practice?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

Please explain your answer. (Maximum 400 words.)

Incentivising preventative and proactive care

QOF and IIF focus on incentivising prevention and proactive care as part of effective population health management, and can provide a helpful counterbalance to the reactive work of meeting on-the-day patient requests.

Question

Do you agree or disagree that QOF and IIF help ensure that sufficient resources are applied to preventative and proactive care?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

Please explain your answer. (Maximum 400 words.)

If you disagree, how else could we ensure that sufficient resources are applied to preventative and proactive care in general practice?  (Maximum 400 words)

Targets and health inequalities

The way targets are set can impact on health inequalities. Currently, absolute thresholds are used for assessing QOF and IIF with some adjustments taking place to account for local disease prevalence and practice list size. All practices and PCNs are expected, however, to meet the same targets, regardless of their current performance, practice characteristics or local population demographics.

The use of absolute thresholds plays a crucial role in bringing all practices closer to nationally agreed standards, helping to ensure that the NHS is delivering value for money. But, if a target is set, say at 85%, and practices achieve this target, it could be argued that the 15% that are missed might be those harder to reach that would have benefitted most from the intervention. The use of relative improvement targets could acknowledge the varying starting positions and populations of individual practices.

Question

Would relative improvement targets be more effective than absolute targets at delivering improvements in care quality while also addressing health inequalities?

  • Yes
  • No
  • Don’t know

Please explain your answer. (Maximum 400 words.)

In what other ways could we use incentive schemes to address health inequalities? (Maximum 400 words)

Role of integrated care boards (ICBs)

Some ICBs have told us that they would like the flexibility to use incentives to address local quality issues affecting their populations. This could be through ICBs having a role in selecting local priority indicators from a national menu, or by strengthening the incentive by putting additional local funding against agreed indicators.

Question

To what degree, if any, do you think that ICBs should influence the nature of any incentive scheme?

  • The scheme should be entirely national
  • ICBs should be able to select local priority indicators from a national menu
  • ICBs should be able to select local priority indicators from a national menu and put additional local funding against those indicators
  • ICBs should be able to choose their own indicators and put local funding against those indicators
  • Don’t know
  • Other

Please explain your answer. (Maximum 400 words.)

PCN-led quality improvement

We want PCNs to foster peer review of data and continuous quality improvement across practices. One approach could be to link incentive payments to PCN rather than practice achievement. 

Question

Do you agree or disagree that a PCN-level incentive scheme like IIF encourages PCN-wide efforts to improve quality?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

Please explain your answer. (Maximum 400 words.)

Scope of any incentive schemes in general practice

This section seeks feedback on additional areas that could be considered for inclusion within future incentive schemes. We are interested in your views on the concepts that these questions introduce and recognise that we could not expand the scope without considering the total number of indicators or the funding impacts that would need to balance effort and reward. 

Quality of care

While we think incentives should prioritise focus on clinical outcomes such as the rates of heart attacks and strokes, we recognise that clinical outcomes are rarely solely shaped by the actions of practices or PCNs alone. Therefore, outcome-based incentives could be perceived as unfair. Other measures can also be effective at boosting desirable activity such as maintaining asthma registries, completing diabetic foot checks or measuring blood pressure, rather than directly rewarding clinical outcomes.

Question

What type of indicators, if any, within incentive schemes do you think most help to improve care quality? (Select all that apply)

  • Clinical coding (for example, accurate recording of smoking status in a patient record)
  • Clinical activity (for example, undertaking an annual asthma review)
  • Clinical outcomes (for example, stroke rates)
  • Quality improvement (QI) (for example, local project to improve patient experience or staff wellbeing)
  • Other
  • Don’t know

If you said ‘other’, please describe the nature of the indicators you think would be effective in improving care. (Maximum 400 words.)

Population levels

One of the challenges with focusing on clinical outcomes is the size of the population at which these are measured. We could choose to incentivise change in an outcome that is measured at a PCN level (with an average population of around 50,000 patients) or at ‘place’ level (250,000 and above population). It is important to note that, as the population level expands, individual practices have less influence, emphasising the need for collaboration and partnership within the PCN or potentially across a place to achieve shared outcomes.

Question

Do you think there is a role for incentives to reward practices for clinical outcomes measured at PCN or place level?

  • Yes - at place and PCN levels
  • Yes - at PCN level only
  • Yes - at place level only
  • No
  • None of the above
  • Don’t know

If you selected ‘none of the above’, please describe how you think we could best focus on clinical outcomes? (Maximum 400 words.)

Reducing pressures on the health system

We believe general practice can help to reduce pressures on the rest of the health system. For instance, through effective management of long-term conditions, general practice can reduce the risk of unplanned hospital admissions.

Question

Do you agree or disagree that there is a role for incentive schemes to focus on helping to reduce pressures on other parts of the health system?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

Please explain your answer. (Maximum 400 words.)

Multiple long-term conditions

We think any incentive scheme should consider the quality of care for patients with multiple, complex long-term conditions. Currently, QOF and IIF are focused on improving care quality for single conditions. The patient population is, however, increasingly characterised by multimorbidity, complexity and frailty, often benefitting from more holistic joined-up care planning and delivery. Government recently published the case for change and strategic framework for the final major conditions strategy.

Question

Do you agree or disagree that incentives should be more tailored towards quality of care for patients with multiple long-term conditions?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

If you said ‘agree’, how could we tailor any incentive scheme more towards quality of care for patients with multiple long-term conditions? (Maximum 400 words.)

If you said ‘disagree’, please explain your answer. (Maximum 400 words.)

Patient access

Improving access to general practice is one of our top priorities, but there are currently no additional payments for practices that excel in providing a positive experience of access for patients. We are particularly interested in your views on whether incorporating indicators for experience of access based on survey data could spur improvement.

Question

Do you agree or disagree that patient experience of access could be improved if included in an incentive scheme?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

If you said ‘agree’, how could patient access be incentivised and measured? (Maximum 400 words.)

If you said ‘disagree’, please explain your answer. (Maximum 400 words.)

Continuity of care

Continuity of care is important to both clinical quality and patient experience of care. This can refer to the relationship between a named GP and their patient, or team-based continuity where patients are happy to see different professionals as part of their overall care.

There could be scope for an incentive scheme to encourage continuity of care using either regular patient survey data or general practice record data to measure achievement. However, we also recognise the importance of patient choice and clinical judgement in identifying which patients need or want continuity of care, and respecting that some patients may prioritise speed and convenience of access over seeing a specific professional.

Question

Do you agree or disagree that continuity of care could be improved if included in an incentive scheme?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

If you said ‘agree’, how could continuity be measured and incentivised? (Maximum 400 words.)

If you said ‘disagree’, please explain your answer. (Maximum 400 words.)

Patient choice

Patients have a legal right to choose where they receive their elective care. On 25 May 2023, the government and NHS England set out how they will increase the awareness of the right to choose, and make it easier for patients to exercise choice and for clinicians to offer it. See NHS England’s letter to the system dated 25 May 2023. To ensure that this offer is more meaningful, we could incentivise patient choice.

Question

Do you agree or disagree that patient choice could be improved if included in an incentive scheme?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

If you said ‘agree’, how could we incentivise and measure patient choice in any incentive schemes? (Maximum 400 words.)

If you said ‘disagree’, please explain your answer. (Maximum 400 words.)

Effective prescribing

General practice plays a crucial role in managing the prescribing of medicines and delivering on our prescribing priorities, such as tackling inappropriate prescribing, problematic polypharmacy, low-carbon prescribing and promoting the use of the most clinically and cost-effective medicines. Many practices already use publicly available data that shows how their prescribing compares with other practices, and we could consider using this type of data as part of an incentive scheme.

Question

Do you agree or disagree that the effectiveness of prescribing could be improved if included in an incentive scheme?

  • Agree
  • Neither agree nor disagree
  • Disagree
  • Don’t know

If you said ‘agree’, how could we incentivise effective prescribing in any incentive schemes? (Maximum 400 words.)

If you said ‘disagree’, please explain your answer. (Maximum 400 words.)

Other comments

Question

If you think there are any other areas that should be considered for inclusion within an incentive scheme, please list them here. (Maximum 400 words.)

Minimising administrative burden

We have heard that QOF and IIF can become ‘tick box exercises’ that distract clinicians from focusing on the needs of their patient and using their clinical judgement. This section seeks your feedback on how we can reduce the administrative effort associated with any scheme, including regarding the number of indicators and the processes associated with delivering the schemes.

Question

What opportunities are there to simplify and streamline any schemes for clinicians, and reduce any unnecessary administrative burden, while preserving patient care? (Maximum 400 words.)

How to respond

Respond through our online consultation survey.

The consultation is open for 12 weeks, and will close at 11:59pm on 7 March 2024 - if you respond after this date, your response may not be considered. 

Respondents are encouraged to answer as many questions as possible, but you do not have to respond to every question.

If you have any questions on the running of this consultation or the information it contains, contact gp_incentives_consultation@dhsc.gov.uk. Do not send any personal information to this email address.

Privacy notice

Summary of initiative

In England, general practices are incentivised through 2 main schemes, the:

  • Quality and Outcomes Framework (QOF)
  • Investment and Impact Fund (IIF)

These schemes aim to enhance healthcare delivery and patient outcomes by incentivising continuous improvement in clinical care and public health delivery.

Practices that achieve the targets set in these schemes receive additional income to their core funding. Earlier this year, we made a commitment to consult with the public and profession on the future of QOF in Changes to the GP contract in 2023 to 2024.

We have expanded the scope so this consultation focuses on the role of both QOF and IIF. 

Data controller

The Department of Health and Social Care (DHSC) is the data controller.

What personal data we collect

DHSC will collect the following data:

  • age
  • sex
  • gender
  • the area of UK in which respondents are based
  • ethnic group
  • field of work
  • job title
  • organisation details
  • email address

How we use your data

The data we collect is to inform the DHSC of the demographic of respondents. The department will process your personal data in accordance with the Data Protection Act 2018 (DPA) and, in most circumstances, this will mean that your personal data will not be disclosed to third parties.

Under the Article 6 of the UK General Data Protection Regulation (GDPR), the lawful basis we rely on for processing this information is:

(e) Necessary task in the public interest or controller’s official authority  

Under the Article 9, conditions for processing special category data, the lawful basis we rely on processing this information is:

(i) Public health (with a basis in law)

Data processors and other recipients of personal data

SocialOptic is the data processor. Services have been procured from Warwick Economics and Development (WECD) to analyse the consultation responses and therefore WECD will also be a data processor.

International data transfers and storage locations

Any personal information collected will be stored in the UK and managed in line with the DHSC’s personal information charter.

Storage of data by SocialOptic is provided via secure servers located in the UK.

Retention and disposal policy

We manage the information you provide in response to this consultation in accordance with the DHSC’s data protection policy. We will retain your data for 12 months after the consultation closes.

We will ask SocialOptic and WECD to securely delete the information held on their system 12 months after the online consultation closes.

How we keep your data secure

DHSC uses a range of technical, organisational and administrative security measures to protect any information we hold in our records from:

  • loss
  • misuse
  • unauthorised access
  • disclosure
  • alteration
  • destruction

DHSC has written procedures and policies that are regularly audited and reviewed at a senior level. DHSC will ensure that WECD is compliant with the department’s data protection requirements.

SocialOptic is Cyber Essentials certified. This is a government-backed scheme that helps organisations protect themselves against the most common cyber attacks.

Your rights as a data subject

By law, data subjects have a number of rights and this processing does not take away or reduce these rights under the EU General Data Protection Regulation (2016/679) and the UK Data Protection Act 2018 applies.

These rights are:

  1. The right to get copies of information - individuals have the right to ask for a copy of any information about them that is used.
  2. The right to get information corrected - individuals have the right to ask for any information held about them that they think is inaccurate, to be corrected
  3. The right to limit how the information is used - individuals have the right to ask for any of the information held about them to be restricted, for example, if they think inaccurate information is being used.
  4. The right to object to the information being used - individuals can ask for any information held about them to not be used. However, this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case.
  5. The right to get information deleted - this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case.

Comments or complaints

Anyone unhappy or wishing to complain about how personal data is used as part of this programme, should contact data_protection@dhsc.gov.uk in the first instance or write to:

Data Protection Officer
1st Floor North
39 Victoria Street
London
SW1H 0EU

Anyone who is still not satisfied can complain to the Information Commissioner’s Office. Their website address is www.ico.org.uk and their postal address is:

Information Commissioner's Office
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF

Automated decision-making or profiling

No decision will be made about individuals solely based on automated decision-making (where a decision is taken about them using an electronic system without human involvement) which has a significant impact on them.

Changes to this policy

This privacy notice is kept under regular review, and new versions will be available on our privacy notice page on our website. This privacy notice was last updated on 5 March 2024.

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