A new study warns of the potential for fraud present in two NHS incentive programmes - the Quality and Outcomes Framework (QOF) for general practitioners (GPs) and pharmacists’ Medicines-Use Reviews (MURs).
QOF is the voluntary reward and incentive programme linking payment to the achievement of quality targets which was introduced in April 2004 as a key component of the new general medical services (GMS) contract. A commonly-held view among GPs interviewed for the study was that QOF is a reward for activities which they were already conducting; one called the performance indicators “a license to print money” because they would require no change to what was already being done at the practice, while another said: “the fact that now we would be paid for what we’d been doing for years without pay was seen as a good thing.”
“We see QOF as the minimum [of] what we aim to achieve,” another told the study, which was funded by the National Institute of Health Research Service Delivery and Organisation Programme to examine, over a three-year period, the impact of incentives on the behaviour and performance of NHS primary care professionals in the NHS.
However, some doctors claimed that other practices have abused the system, and the researchers say they are particularly worried about the report of data falsification in one practice where, according to a Primary Care Trust (PCT) manager reports, fraud was spotted “red-handed.”
“We had a GP that managed to record 48 blood-pressure readings in the space of half an hour,” said the manager, adding: “we’re the highest recorders of chronic kidney disease in England because we didn’t pay practices where we thought their register sizes were too low.”
Commenting on these claims, the researchers say that while the extent of such data falsification is not known, “the fact that PCTs many not be monitoring QOF in a sufficiently detailed manner, as suggested by one of our commissioners, gives some cause for concern.”
“Everybody is a high achiever. I was a QOF assessor for four years or five years, and I am also writing a book on fraud in the NHS, to put the two together,” one GP partner told the study.
Turning to pharmacists' MURs, the researchers found that while in some cases the review targets were considered worthwhile and fulfilling, in others “they were depicted as cursory and/or bordering on fraudulent.”
By and large, GPs interviewed for the study consider MURs to be a waste of time and money, and many pharmacists told it that they represent “just doing what we have always done;” as a result, they were unhappy about financial incentives generally and having to ask patients to sign the forms which pharmacies submit to be paid for conducting MURs. However, a “small number” of pharmacists admitted that they had chosen to conduct reviews which are “less resource-intensive, of limited benefit and cursory in nature.”
The researchers have other concerns about the value of MURs, noting that, “with many users of medicines being knowledgeable actors, a model of MUR delivery which treats individuals as passive recipients of expert advice appears to be an inappropriate response.” Moreover, where the increasingly competitive retail pharmacy environment is creating pressure to prioritise income targets over responding to the needs of service users, “the potential of MURs to enhance professional status and encourage partnerships with patients appears to be limited,” they say.