Longitudinal evaluation of a countywide alternative to the Quality and Outcomes Framework in UK General Practice aimed at improving Person Centred Coordinated Care

Abstract

Objectives
To evaluate a county-wide deincentivisation of the Quality and Outcomes Framework (QOF) payment scheme for UK General Practice (GP).

Setting
In 2014, National Health Service England signalled a move towards devolution of QOF to Clinical Commissioning Groups. Fifty-five GPs in Somerset established the Somerset Practice Quality Scheme (SPQS)—a deincentivisation of QOF—with the goal of redirecting resources towards Person Centred Coordinated Care (P3C), especially for those with long-term conditions (LTCs). We evaluated the impact on processes and outcomes of care from April 2016 to March 2017.

Participants and design
The evaluation used data from 55 SPQS practices and 17 regional control practices for three survey instruments. We collected patient experiences (‘P3C-EQ’; 2363 returns from patients with 1+LTC; 36% response rate), staff experiences (‘P3C-practitioner’; 127 professionals) and organisational data (‘P3C-OCT’; 36 of 55 practices at two time points, 65% response rate; 17 control practices). Hospital Episode Statistics emergency admission data were analysed for 2014–2017 for ambulatory-sensitive conditions across Somerset using interrupted time series.

Results
Patient and practitioner experiences were similar in SPQS versus control practices. However, discretion from QOF incentives resulted in time savings in the majority of practices, and SPQS practice data showed a significant increase in P3C oriented organisational processes, with a moderate effect size (Wilcoxon signed rank test; p=0.01; r=0.42). Analysis of transformation plans and organisational data suggested stronger federation-level agreements and informal networks, increased multidisciplinary working, reallocation of resources for other healthcare professionals and changes to the structure and timings of GP appointments. No disbenefits were detected in admission data.

Conclusion
The SPQS scheme leveraged time savings and reduced administrative burden via discretionary removal of QOF incentives, enabling practices to engage actively in a number of schemes aimed at improving care for people with LTCs. We found no differences in the experiences of patients or healthcare professionals between SPQS and control practices.

Full text

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CloseJ, etal. BMJ Open 2019;9:e029721. doi:10.1136/bmjopen-2019-029721
Open access
Longitudinal evaluation of a
countywide alternative to the Quality
and Outcomes Framework in UK
General Practice aimed at improving
Person Centred Coordinated Care
James Close, 1 Ben Fosh,1 Hannah Wheat,2 Jane Horrell,1 William Lee,1
Richard Byng,3 Michael Bainbridge,4 Richard Blackwell,5 Louise Witts,5
Louise Hall,5 Helen Lloyd6
To cite: CloseJ, FoshB,
WheatH, etal. Longitudinal
evaluation of a countywide
alternative to the Quality and
Outcomes Framework in UK
General Practice aimed at
improving Person Centred
Coordinated Care. BMJ Open
2019;9:e029721. doi:10.1136/
bmjopen-2019-029721
►Prepublication history and
additional material for this
paper are available online. To
view these les, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2019-
029721).
Received 7 February 2019
Revised 23 May 2019
Accepted 30 May 2019
For numbered afliations see
end of article.
Correspondence to
DrJames Close;
james. close@ plymouth. ac. uk
Research
© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY-NC. No
commercial re-use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Objectives To evaluate a county-wide deincentivisation
of the Quality and Outcomes Framework (QOF) payment
scheme for UK General Practice (GP).
Setting In 2014, National Health Service England
signalled a move towards devolution of QOF to Clinical
Commissioning Groups. Fifty-ve GPs in Somerset
established the Somerset Practice Quality Scheme
(SPQS)—a deincentivisation of QOF—with the goal of
redirecting resources towards Person Centred Coordinated
Care (P3C), especially for those with long-term conditions
(LTCs). We evaluated the impact on processes and
outcomes of care from April 2016 to March 2017.
Participants and design The evaluation used data from
55 SPQS practices and 17 regional control practices for
three survey instruments. We collected patient experiences
(‘P3C-EQ’; 2363 returns from patients with 1+LTC; 36%
response rate), staff experiences (‘P3C-practitioner’; 127
professionals) and organisational data (‘P3C-OCT’; 36 of
55 practices at two time points, 65% response rate; 17
control practices). Hospital Episode Statistics emergency
admission data were analysed for 2014–2017 for
ambulatory-sensitive conditions across Somerset using
interrupted time series.
Results Patient and practitioner experiences were similar
in SPQS versus control practices. However, discretion from
QOF incentives resulted in time savings in the majority of
practices, and SPQS practice data showed a signicant
increase in P3C oriented organisational processes,
with a moderate effect size (Wilcoxon signed rank test;
p=0.01; r=0.42). Analysis of transformation plans and
organisational data suggested stronger federation-
level agreements and informal networks, increased
multidisciplinary working, reallocation of resources
for other healthcare professionals and changes to the
structure and timings of GP appointments. No disbenets
were detected in admission data.
Conclusion The SPQS scheme leveraged time savings
and reduced administrative burden via discretionary
removal of QOF incentives, enabling practices to engage
actively in a number of schemes aimed at improving
care for people with LTCs. We found no differences in
the experiences of patients or healthcare professionals
between SPQS and control practices.
BACKGROUND
The Quality and Outcomes Framework
(QOF) for UK General Practice (GP) is one
of the largest health-related pay-for-perfor-
mance (P4P) schemes in the world.1 Following
implementation in 2004, the scheme initially
had a positive impact on quality of care,
primarily achieved via establishment of
consistent procedural baselines in the clin-
ical management of incentivised (mostly
chronic) diseases.1–5 It reduced between-prac-
tice inequalities in care delivery,1–3 while
Strengths and limitations of this study
►This study evaluated changes to service delivery,
conducted using two survey tools—offering a per-
spective on the experiences of both patients and
healthcare professionals.
►These were supplemented with a longitudinal analy-
sis of organisational change (to measure alterations
to service deliver) and a timeseries of emergency
admissions for ambulatory-sensitive conditions (to
detect disbenets arising from the scheme).
►Due to time and resource pressures on general
practice in the UK, we struggled to recruit controls
from within the same county (Somerset) or matched
controls from the region. As an alternative, we ob-
tained non-matched controls from the region.
►No detectable improvements were established in
experiences of healthcare professionals or pa-
tients—this could be because the intervention had
no effect on these outcomes, the instruments were
not sensitive enough or changes to patient/practi-
tioner experiences were somewhat distal to the
intervention.
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Open access
also leading to improved disease registers, widespread
recording of clinical activities and adoption of electronic
medical record systems,1 leading to growth in GP data
and related research.6 7
Since the introduction of QOF, demographic shifts of
an aging population have continued to drive a shifting
clinical landscape,8 with the number of people with
three or more long-term conditions (mLTCs) thought
to have risen by one million over the last decade.9 The
subsequent rising demand for the management of long-
term conditions (LTCs) and mLTCs—requiring tailored
and coordinated support10 11—has led to QOF (with its
emphasis on processes for single disease guidelines)
being viewed as increasingly anachronistic.6 12–16 After
introduction of QOF, there was a significant reduction
in the continuity of care2 17 and the person-centeredness
of GP consultations,13 14 18 19 with a subsequent decline in
patients’ satisfaction.20 It has been argued that QOF does
not incentivise appropriate clinical care for people with
multimorbidity,6 12–16 who require individualised support,
greater continuity of care and a holistic, biopsychosocial
approach that is responsive and empowering.10 11 An
oft-quoted criticism is that QOF reduces consultations to
a ‘box-ticking’ exercise.21
In response to such criticisms, both the National
Health Service (NHS) Chief Executive and the General
Practitioners Committee Chairman previously backed
the removal of QOF.21 In 2014, NHS England signalled
a move towards devolution of QOF to Clinical Commis-
sioning Groups (CCGs), allowing organisations the
freedom to develop alternatives. Potential advantages
included the targeting of local health needs and greater
clinical engagement for quality improvement.22 In
response, the Somerset Practice Quality Scheme (SPQS)
was established as a deincentivisation of QOF. It arose
because GPs, the CCG and the Local Medical Committee
felt that QOF was not incentivising the highest value
clinical behaviour. The goal was to allow clinicians
the freedom to innovate, enable consultations to be
more person-centred and increase involvement with a
number of concurrent schemes aimed at improving
Person Centred Coordinated Care (P3C).23 The details
of the scheme were included in the SPQS contract24 and
local Sustainability and Transformation Plan (STP—
plans for reforming healthcare mandated by the Five-Year
Forward View25) of the GPs26 (see online supplementary
file 1 for a summary of Somerset STPs; box 1 for brief
details of the various schemes and references for details).
The contract removed incentives from QOF, although
Calculating Quality Reporting System (CQRS) remained
active in order to collect prevalence data for payment
calculations. The SPQS contract stated that the reduced
QOF overhead would be exploited to better meet the
needs of patients with LTCs by developing new models of
care. Implementation was specified in the locality STPs,
which included a patchwork of initiatives, most notably
the ‘Test and Learn pilots’, which encompassed three
distinct schemes (box 1), all of which had a shared vision
of targeting complex patients with care plans, multi-
disciplinary team input and single point of contact.27 28
Other schemes included a Village Agents service29 and
Health Connections Mendip (HCM)30—see box 1. Fifty-
five Somerset practices opted for SPQS, with 18 Somerset
practices (initially 20) retaining the existing QOF contract
(the SPQS practices increased to 57 in 2015/16; but two
mergers reduced it back to 55).
The initial phase of the scheme was previously evalu-
ated with a retrospective approach.31 This revealed early
stages of organisational change, including stronger feder-
ation-level agreements and informal networks, increased
multidisciplinary team working, reallocation of resources
towards healthcare assistants, nurses and others, and
changes to structure and timings of appointments with
GPs. From April 2016 to March 2017, we conducted
a longitudinal evaluation of the second full year of the
SPQS programme (see online supplementary file 2 for a
timeline of the SPQS scheme and associated evaluations).
This was commissioned with the aims of establishing the
nature and extent of P3C that has been implemented
Box 1 Initiative for implementation of SPQS.
Test and Learn:Comprises three similar initiatives (South Somerset
Symphony Vanguard, Taunton and Mendip—see below), which share
a common goal of targeting complex, multimorbid patients with a suite
of approaches including single personalised care plans, multidisci-
plinary team input and single point of access to provide PersonCentred
Coordinated Care.
Test and Learn—South Somerset Symphony Vanguard:A sym-
phony ‘hub’ system located at Yeovil District Hospital, where com-
plex patients receive extra support from health coaches(HCs)/Key
Workers at the Symphony hub service, although they remain under
management of general practice (GP).27 28
Test and Learn—Taunton: Operates under a ‘virtual hub’ model,
with complex/frail patients managed by a multidisciplinary team
moving between practices, with shared care plans and Well-being
Advisors.
Test and Learn—Frome Mendip, including ‘Health Connections
Mendip’: With loose eligibility criteria and a number of referral
routes, Community Practice Nurse and Health Connectors (based
at Frome) liaise regularly in multidisciplinary team input meetings.
There is a hub telephone line for single point of access. The mod-
el advocates using existing assets in the community. The Health
Connections team lead social prescribing work with a service direc-
tory to signpost patients to appropriate resources.30
Enhanced Primary Care (EPC): EPC is a subcomponent of the
Symphony Vanguard scheme that incorporates HCs into primary care,
focusing on less complex patients, allowing GPs to focus primarily on
medical problems.
Village Agents Service: Supports isolated, excluded and vulnerable
(including elderly and multimorbid) people by offering a signposting and
referral service. The service links with GPs.29
Living Better:A working partnership between the GP, AGE UK Somerset,
Social Care, Somerset Partnership, West Somerset District Council and
Somerset Clinical Commissioning Group. The project supports people
with one or more long-term conditions to better self-manage, helping
them build connections to the community and reducing dependency on
health and social care.
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since discretion from QOF, explore staff and patient
experiences of care delivery and examine non-elective
hospital admissions before and after inception of the
scheme.
METHODS
We conducted a mixed-methods evaluation of SPQS
which included a suite of quantitative and qualitative
tools. Analysis of quantitative data is described in this
paper. In-depth qualitative findings will be published in
a subsequent paper (including semistructured interviews
with practitioners, observations of consultations and facil-
itation workshops with practices). A schematic overview
of the full SPQS evaluation framework is provided in
figure 1. The quantitative evaluation included completion
of survey tools targeting patient experiences (P3C-EQ),
staff experiences (P3C-practitioner) and organisational
perspectives (P3C-OCT tool), alongside time series of
Hospital Episode Statistics (HES) for ambulatory-sensitive
conditions across Somerset. We chose not to use national
measures of GP (ie, GP Patient Survey and Friends and
Family Test): they have a broad sample and do not target
the patient group (ie, patients with LTCs) that are the
focus of SPQS. Furthermore, they do not target the
construct of interest (ie, P3C).
Samples
The 55 participating Somerset practices (mean list
size=7695; median=6515.5; smallest=1834; largest=29 078)
completed our evaluation tools (see below). While these
55 practices were incentivised to take part in our evalua-
tion (ie, by being part of SPQS), the non-SPQS Somerset
practices had no incentive to act as controls and did not
participate in this study. Therefore, for control practices,
we initially identified a cohort of non-Somerset control
practices matched for staffing data, list size, population
density, indices of multiple deprivation, QOF scores and
disease prevalence. However, the incentives available for
this evaluation (£200 per practice) were only sufficient to
recruit six practices by this method. We therefore supple-
mented this group with 11 unmatched practices from
across the Southwest, making a total of 17 control prac-
tices (mean list size=6714; median=4878; smallest=2678;
largest=4878). The control group therefore represents a
self-selected sample of practices that are likely to repre-
sent engaged, active practices (ie, with the resources to
engage with research). In contrast, completion of our
evaluation was mandatory for all SPQS practices.
Patient and public involvement
Patients were involved via the peninsula CLAHRC
patient involvement group (PenPig), who set priorities
for research objectives. Patients, public and healthcare
professionals were also involved in codesign workshops
to develop the measurement framework and individual
questionnaires (see papers for details23 32–37). Patients
also reviewed drafts of ethics approval applications
and all patient-facing communication. The work was
copresented with patients at the South West Society for
Academic Primary Care Regional Meeting 2018.
Figure 1 Our P3C mixed methods evaluation framework for SPQS2.LTC, long-term condition; P3C, Person Centred
Coordinated Care; QOF,Quality and Outcomes Framework; SPQS,Somerset Practice Quality Scheme.
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Survey tools
The P3C-Patient Experience Questionnaire (P3C-EQ) is a brief,
11-item patient-completed measure of patient experi-
ences of P3C delivery, which we have previously vali-
dated.32 38 39 The tool can be used to generate an aggregate
score of patient experience,32 with a range of score from
0 to 30, where a higher score indicates better experiences
of care.39 It can also be subscored to previously described
subdomains of P3C.23 32 34–37
The P3C-Practitioner Experience Survey is a 29-item instru-
ment that measures individual and managerial experience
of delivering P3C. Via a workshop with healthcare profes-
sionals, we selected the previously validated P3C-Practi-
tioner questionnaire (also known as the Person-Centred
Healthcare for Older Adults Survey40) as the most suit-
able instrument to examine practitioners’ perspectives
of P3C (see online supplementary file 3). A minimum of
two practitioners from each practice were requested to
respond. The instrument generates an aggregate score
with a range of 29–145, where a higher score indicates
better experiences of care.
The P3C-Organisational Change Tool (P3C-OCT) is an
evidenced-based measure of progress towards delivering
P3C from an organisational perspective.33 It was devel-
oped to support and measure P3C in line with Year of
Care34 and RCGP Principles of Collaborative Care and
Support Planning,41 thus providing a way to monitor
changes in line with policy directives which improve P3C.
The tool was designed to measure all core P3C routines,
which have been identified through research,42 43 patients’
accounts, policy documents34 and our own work.23 33 The
design of the P3C-OCT is based on a shared consensus of
the components of P3C (eg,35 36 44), which broadly corre-
spond to six domains: Information and Communication,
Care Planning, Goals and Outcomes, Transitions, Organ-
isational Process Activities and Decision Making. These
domains have been mapped to real-world actions that
support the delivery of P3C (eg, multidisciplinary team
meetings, care planning, provisions for information).
This allows the tool to translate concepts that are often
abstract and may be drawn from academic literature and
policy documents, into actionable, tangible processes
which a practice can implement. The result is a unique
29-question instrument with over 500 different possible
responses, which provides a detailed and practical inter-
rogation of P3C delivery. An equally weighted scoring
system allows results of the P3C-OCT to be aggregated
into a single composite score, or alternatively by subdo-
mains of P3C—generating a score of 0–20, with higher
scores indicating more P3C-related activity.
The P3C-OCT provides a detailed profile of care
delivery and organisation through 29 core questions.
All questions ask about objective activities (eg, processes
in place to deliver P3C) and subjective responses (eg,
how well these are working). Scores are given out of a
theoretical maximum of 20 points. The P3C-OCT was
also prepended by a series of SPQS-related questions
about administrative and consultation time savings from
discretion from QOF. Each SPQS practice was requested
to complete the P3C-OCT at two time points (from
February to August 2016 and December 2016 to March
2017). In contrast, control practices only completed the
P3C-OCT once (at time 2).
Data collection
All participating practices supported data collection
of the three survey tools. With the P3C-EQ, from each
practice, 100 patients with one or more LTCs, randomly
sampled from the practice list (using a customised EMIS
script), were invited to complete a postal questionnaire
at a single time point. Patients received an information
pack, consent sheet, demographic questionnaire and
P3C-EQ. All returned questionnaires were entered into a
Microsoft Access database prior to statistical analyses. For
the P3C-Practitioner, we obtained an opportunity sample
via both written and email communication with all partic-
ipating practices. For the P3C-OCT, all participating prac-
tices were offered an electronic or paper version, and we
requested that the tool was completed by a combination
of General Practitioner and Practice Manager (PM), thus
ensuring representation of front-facing and backend
operations of GP surgeries. Completion of the tool was
mandatory as part of the SPQS evaluation.
Analysis
SPQS and control practices were compared on the
P3C-Patient Experience Survey and the P3C-Practioner
Experience Survey (at time 2; 6–12 months after initiation
of second year/phase 2 of SPQS), with significance tested
using the non-parametric unmatched Mann–Whitney–
Wilcoxon (MWW) test taking into account within-practice
clustering by calculating Somers’ D statistic (non-para-
metric tests were used, as the scoring is a summation of
Likert responses, ie, data were ordinal). For the P3C-Or-
ganisational Change Tool, we compared time 1 (imme-
diately after implementation of second year/phase 2 of
SPQS) and time 2 (6–12 months later), with significance
evaluated by Wilcoxon signed-rank test.
Time series of emergency admissions to hospital
A multigroup interrupted time-series analysis (ITS)
was conducted to identify whether deincentivisation
of QOF and the introduction of SPQS were associated
with changes in emergency admissions to acute hospitals
with a primary diagnoses for four long-term, ambulatory
care sensitive conditions (ACSCs). HES were obtained
for patients from all 55 GP practices enrolled in the
SPQS scheme (actually 56 practices in 2015/15) and
18 Somerset QOF practices (ie, Somerset practices not
enrolled in SPQS; initially 20). Data were obtained for a
70-month period from April 2011 to May 2018. This time
period is divided into 38 months preintervention (April
2011 to May 2014) and 48 months postintervention (June
2014 to May 2018; SPQS contract went live in June 2014,
month 39). Data include monthly admission counts for
four ACSCs: Acute Myocardial Infarction (AMI), Chronic
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Obstructive Pulmonary Disease (COPD), Diabetes and
Stroke. We selected these ACSCs as a proxy for prevent-
able admissions and an indicator of any deteriorating
quality of care associated with SPQS. Due to the differ-
ence in number of practices between SPQS and QOF
practices, admissions were divided by the number of prac-
tices, thus providing an average of emergency admissions
(expressed as admissions per month per practice). Anal-
ysis was performed using the itsa command45 on STATA
(StataCorp Ltd). This uses regression-based model with
Newey-West standard errors. Preintervention and postin-
tervention slopes/intercepts of the sample (SPQS prac-
tices) were compared with controls (QOF practices). Lag
period was set to 1 month.
RESULTS
Person Centred Coordinated Care-Patient Experience
Questionnaire
There were 1752 responses received from 49 (89%) of
the 55 practices enrolled in SPQS and 611 responses
from patients enrolled in the 17 control (QOF) practices
(36% response rate and similar to other studies46). The
responses of the two groups were compared in table 1.
The mean global aggregated scores for the P3C-EQ for
SPQS (23.39, n 1752) and QOF controls (23.68, n 611)
were not significantly different (MWW U test; p=0.346)
and indicate generally positive experiences of care across
both samples.
P3C-Practitioner results
Full results of the P3C-Practioner are provided in online
supplementary file 3. We received 98 responses from 55
SPQS practices and 29 responses from 18 control prac-
tices from a mix of healthcare professionals—62 GPs
(49%); 35 nurses (27%); 12 well-being advisors; 7 LTC
nurse; 11 others. The mean global aggregated scores for
the P3C-EQ for SPQS (23.39, n 1752) and QOF controls
(23.68, n 611) were not significantly different (MWW test;
p=0.405). Return rates are not applicable, as this was a
convenience sample where we requested response from
at least two different professionals at each practice.
P3C-OCT results
To evaluate changes to P3C during the SPQS scheme, we
undertook an analysis of the organisation and delivery
of care using the P3C-OCT. Of 55 practices enrolled in
the scheme, 36 practices provided admissible data (ie,
complete and timely) at the two evaluation time-points
(time 1: 2/2016–8/2016 and time 2 was 12/2016-5/2017;
65% response rate). This revealed an increase (0.9;
p=0.034) in aggregate scores on the P3C-OCT between
T1 (5.8) to T2 (6.7). This therefore represents a measur-
able increase in activity towards P3C delivery and organi-
sation (see table 2), with a moderate effect size (r=0.42).
To determine the specific areas of P3C that improved
during the evaluation, this was examined by domains
of P3C.34–36 When broken into subdomains of P3C,
Table 1 Demographic prole of responses to P3C-EQ as percentages
Participant demographics as a percentage
Age(years) Education Gender Multimorbidity
QOF SPQS QOF SPQS QOF SPQS No. LTCs QOF SPQS
<=24 0.3 0.4 None 1.0 1.3 Male 44.0 43.4 1 19.6 20.1
25–34 2.5 1.3 Primary 3.1 2.1 Female 53.8 53.9 2 19.6 23.8
35–44 2.5 2.6 Secondary 33.7 34.6 Non-response 2.2 2.7 3 20.6 17.8
45–54 8.8 5.3 College/vocational 26.4 28.1 4 11.3 13.7
55–64 18.3 13.3 Undergraduate 11.5 10.8 5 9.3 7.5
65–74 25.7 29.2 Postgraduate 8.2 7.8 6 4.7 5.1
75–84 29.3 32.7 Non-response 16.2 15.3 7 2.8 2.8
>=85 12.1 14.1 >=8 4.2 2.8
Non-response 0.5 1.0 Non-response 7.9 6.4
LTC, long-term conditions; P3C-EQ, PersonCentred Coordinated Care-Patient Experience Questionnaire; QOF, Quality and Outcomes Framework; SPQS, Somerset Practice Quality Scheme.
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significant improvements were delivered in areas related
to ‘Goals and Outcomes’ (eg, goal setting with patients;
1.7 increase, p=0.00; large effect size r=0.61).
Further to the longitudinal analysis, SPQS practices
were also compared with a cohort of 17 non-SPQS prac-
tices from the South West (all control practices returned
data at time 2). Aggregate results for the P3C-OCT
revealed that control practices had an aggregate score
of 6.2 on the P3C-OCT, with no significant difference
between SPQS and control practices either before (a
score of 5.8 vs 6.2; p=0.64) or after (6.7 vs 6.2; p=0.41) the
intervention.
Discretion from QOF and time savings
When asking SPQS practices to complete the P3C-OCT,
we also included a number of additional questions
related to the SPQS scheme. We asked SPQS practices a
subjective appraisal of time savings (both in GP consulta-
tions and administration) from enrolment in the scheme.
These are shown in figure 2. More than half (55%) of
the practices (28 of 51 practices that completed these
questions) agreed that time had been freed up within the
10 min standard consultation time.
With regard to administrative time savings, more than
three quarters of SPQS practices (40/51; 78%) reported
administrative (non-consultation time for practitioners)
time savings since initiation of the scheme, with just over
one third of these practices (14/51; 27%) reporting gains
of more than 2 hours per week. For administrators and
non-clinical staff, SPQS was reported to free up time
for more than 86% (44/51) of practices with only 13%
(7/51) reporting a negligible effect. Free text response
boxes confirmed the plans of the STPs (see introduc-
tion and online supplementary file 1), stating that effi-
ciency had been leveraged for increased collaborative
and federation-level working, including engagement with
a number of schemes in Somerset designed to improve
P3C, for example, ‘Better use of Symphony’, ‘Engage-
ment with EPC’, ‘Rural Practice Network’, ‘Health
coaches’, ‘Huddles’, ‘P3C relevant training’, ‘Replaced
by other work such as Symphony/health coaching’. ‘This
hasn't shown a reduction in workload but rather a change
in workload.’ In this manner, the time savings leveraged
from QOF were not hypothesised to lead to an improve-
ment of experiences for practitioners, but instead a shift
in workload.
Retention of QOF elements
When asking SPQS practices to complete the P3C-OCT,
we also included a number questions specific to the
implementation of SPQS. When asked ‘Are you still
using components of the QOF?’, nearly all practices
enrolled in SPQS continued to use at least some aspects
of QOF (only 1 out of 51 respondents to this question
stated ‘none’; 86% of practices used ‘Some’, ‘Most’ or
‘All’). We further investigated the continued utilisation
of QOF via a free-text response in the P3C-OCT ques-
tionnaire. This revealed that QOF was still (according to
one practice) used by ‘applying individually’, not 'point
scoring’. A common aspect that was dropped was excep-
tion reporting, with time also being saved by avoiding
‘target chasing’. Elements of QOF were also contractually
retained such as the CQRS. This remained active under
the SPQS contract to allow data on prevalence and key
indicators to be collected from practices via GP Extraction
System (GPES), where prevalence figures are used in the
SPQS payments calculation.
QOF also continued to be used for the monitoring
of LTCs and recall of patients with LTCs for routine
check-ups. Around a half of SPQS practices (n=25) still
use QOF for recall of at least some (or all) conditions (eg,
checking for recall requirements for patients with LTCs
and the management of specific chronic diseases). Free
text responses suggested that while recall was an essen-
tial function, the implementation under QOF was overly
burdensome and not tailored for multiple morbidities.
Some practices countered this by running in-house devel-
oped searches with a priority to ‘concentrate on an inte-
grated LTC system’. This suggests that there is scope for
collaboration to design an overhauled, integrated recall
system that is specifically designed for efficient manage-
ment of multiple LTCs (as previously proposed47 48).
Time series of hospital episode statistics
Results of the ITS are shown in figure 3. No significant
increases were detected in the slope postintervention (ie,
after the initiation of the SPQS contract in June 2014) in
emergency admissions for patients with a primary diag-
nosis of four ACSCs in SPQS practices. Full results of
Table 2 Mean changes in P3C-OCT scores between time 1
and time 2 for 36 paired practices
Time 1 Time 2
Change T1→ T2
(pvalue; effect size)
Total OCT Score 5.8 6.7 0.9 (p=0.01; r=0.42)*
Information and
Communication
7.4 8.1 0.7 (p=0.25; r=0.19)
Care Planning 6.6 7.2 0.6 (p=0.14; r=0.25)
Goals and
Outcomes
6.1 7.8 1.7 (p<0.001; r=0.61)*
Transitions 4.9 5.2 0.3 (p=0.43;r=013)
Organisational
Process Activities
4.3 5.2 0.9 (p=0.03;r=0.36)
Decision Making 3.8 4.4 0.6 (p=0.07;r=0.3)
The top row provides the total OCT score (out of a maximum of
20), followed by domains of P3C. The OCT score for each domain
is given for time 1, time 2 and the difference between time 1 and
2. The statistical signicance of these differences is indicated by
p value from Wilcoxon signed-rank test. Statistically signicant
results (at the level p<0.008; corresponding to a Bonferroni
adjustment for six tests at the p<0.05 signicance level) are
indicated in bold font and with * next to the p value. Effect sizes
were calculated as test statistic z by the square root of the number
of pairs.
OCT,Organisational Change Tool; P3C, Person Centred
Coordinated Care.
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significance tests are provided in online supplementary
file 4. The removal of QOF has had no significant effect
on emergency admissions for these four ACSCs at the
time of intervention or in the 2 years following. However,
for the non-SPQS Somerset practices, a significant slope
change (increase) in admissions for AMI and diabetes
was observed, and a significant slope change (decrease)
for admissions for stroke was observed. These changes in
admissions are therefore unrelated to the SPQS contract
(see discussion below).
DISCUSSION
We observed a variety of responses to deincentivisation
of QOF in Somerset. Some QOF-related components
remained mandatory (prevalence reporting). Some
‘desirable’ features of the QOF system were still used
(eg, prompts during consultation), others were adapted
(eg, patient recall) and some burdensome components
dropped altogether (eg, exception reporting).
Practices reported that these alterations had led to
time and resource savings in both GP consultations
and administration. These time savings were used to
increase involvement in implementation projects such
as Symphony Test and Learn, Village Agents, Health
Connections and the South Somerset Vanguard. These
were planned as part of the SPQS contract and associ-
ated ongoing healthcare reforms. These local imple-
mentation projects are actively targeting service redesign
for complex patient needs, using P3C across practice
contexts. These projects have involved stronger federa-
tion-level agreements and informal networks, increased
multidisciplinary team working, reallocation of resources
for healthcare assistants (including Health and Well-being
Advisors and Health Coaches), nurses and others, single
points of access for the patient, shared electronic record
systems, increased use of care planning and changes to
structure and timings of GP appointments. The results
of our longitudinal P3C-OCT survey confirm significant
improvements in P3C, suggesting that SPQS has been
successful in its stated aims as a system lever for service
redesign aimed at the delivery of greater person-centred
and coordinated primary care.
While there is emerging evidence that P3C approaches
can improve outcomes (particularly for complexity/
Figure 2 Consultation time savings (top left), administrative GP time savings (top right) and non-GP administrative time
savings (bottom left). Percent responses for 51 practices enrolled in Somerset Practice Quality Scheme.GP,General Practice;
QOF,Quality and Outcomes Framework.
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8CloseJ, etal. BMJ Open 2019;9:e029721. doi:10.1136/bmjopen-2019-029721
Open access
multimorbidity),36 49 we could not establish that the
changes introduced via SPQS are leading to better
outcomes for patients. Patient experience is downstream
of the organisational changes occurring in Somerset, and
any detectable improvement in patient outcomes may
be delayed. The results of the patient P3C-EQ experi-
ence established a similar experience of care in Somerset
compared with the control QOF practices (who repre-
sent active, research engaged organisations, whereas
completion of the survey was mandatory for SPQS prac-
tices; see Methods). Similarly, comparison of practitioner
perspective of P3C to the control group revealed similar
experiences in SPQS versus the control practices. These
findings are broadly reflective of results from other initia-
tives, where—for example—patient-centred care for
multimorbid patients recently revealed mixed effects on
processes of care, but was not associated with measur-
able improvements in quality of life or other secondary
outcomes, with the authors concluding that the initia-
tive ‘supported changes in organisation more than it
supported changing the clinicians' attitudes on which
patient-centredness depends.’50
In reference to disbenefits, we could find no evidence of
increased admissions associated with SPQS. However, ITS
did establish trend changes in admissions in non-SPQS
Somerset practices (eg, those practices that retained the
QOF contract). A significant increase was observed in
admissions with a primary diagnosis of AMI and Diabetes,
and a significant decrease observed for those with a
primary diagnosis of Stroke. It is, however, unlikely that
relatively minor changes to QOF in the years 2014/15 and
2015/1651 52 have led to these observed trend changes in
emergency admission.
While the time series did not establish any disbenefits in
SPQS practices, earlier evaluation of SPQS established that
deincentivisation of QOF leads to inconsistent recording
of QOF data. Subsequently, analysis of QOF scores have
little utility in assessing the quality of care in Somerset.31
This paucity of data represents a major disbenefit of QOF
deincentivisation: one of the primary benefits of QOF has
been the widespread recording of clinical activities1 and
availability of GP data and research.6 7 It is not currently
clear how ‘quality’ could be assessed in the post-QOF
landscape—a question that has major implications for
research, evaluation, healthcare management.
Limitation of the study
The ability to draw firm conclusions from this study was
limited by several factors. Due to time and resource pres-
sures on GP in the UK, we struggled to recruit controls
from within the same county (Somerset) or matched
controls from the region. As an alternative, we obtained
Figure 3 Results of interrupted time-series analysis. The four graphs show the ITS for the four ACSCs (from left to right,
top to bottom, the graphs are: Acute Myocardial Infarction (AMI), Chronic Obstructive Pulmonary Disease (COPD), Diabetes
and Stroke). Data starts at April 2011 and ends at January 2017. The SPQS contract was live from June 2014 (ie, intervention
start time, indicated by vertical dashed line). Y-axis gives the number of admissions, normalised as admissions per month per
practice. Black circles indicate the average number of emergency admissions in each month for SPQS practices; white circles
are average admissions for QOF Somerset practices. The regression lines preintervention and postintervention are shown
unbroken (for SPQS) and dashed (for QOF Somerset practices). All changes between preintervention and postintervention
between SPQS and QOF practices are non-signicant (see online supplementary le 4).ACSCs,ambulatory care sensitive
conditions; ITS,interrupted time-series analysis; QOF,Quality and Outcomes Framework; SPQS,Somerset Practice Quality
Scheme.
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Open access
non-matched controls from the region. These repre-
sented a biased cohort of research-engaged practices. We
could not detect improvements in experiences of health-
care professionals or patients—this could be because
the intervention had no effect on these outcomes, the
instruments were not sensitive enough, the controls were
unsuitable or changes to patient/practitioner experi-
ences were somewhat distal to the intervention. A further
limitation of the study methods was that P3C-OCT was
only administered to control practices at the second time-
point, meaning that we cannot determine if significant
improvements of P3C-OCT score in SPQS practices might
also have been present in controls.
Implications for the future
While previous calls for the removal of QOF in England53
have not been reiterated, recent policy has moved towards
a reformed, streamlined version of QOF.54 55 With QOF
continuing to evolve, lessons from SPQS have implica-
tions for UK policy. We have previously made a number
of suggestions for the future landscape of QOF.47 48 These
include retaining limited components of QOF (eg, those
elements that are desirable by GPs; ‘QOF-Lite’), the
development of novel systematic data capture (including
GP contact data) or collaboration on an overhauled, inte-
grated recall system that is specifically designed for effi-
cient management of multiple LTCs.47 48 GP, however, is
under huge time and resource pressures.56 Any proposed
alternatives will have to fulfil the primary requirements of
being a streamlined process for supporting coordination
of care, especially for those with complex health needs.
The recent national review of QOF concluded that QOF
should be reformed to become more person-centred,
create space for professionalism and optimally impact
wider population health and system resource utilisation.57
Author afliations
1Community and Primary Care Research Group, University of Plymouth, Plymouth,
UK
2Sociology, Philosophy and Anthropology Department, University of Exeter, Exeter,
UK
3Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
4NHS Somerset Clinical Commissioning Group, Yeovil, UK
5South West Academic Health Science Network, Exeter, UK
6Psychology, University of Plymouth, Plymouth, UK
Acknowledgements This research was supported by the National Institute for
Health Research (NIHR) Collaboration for Leadership in Applied Health Research
and Care South West Peninsula. The views expressed are those of the author(s) and
not necessarily those of the NHS, the NIHR or the Department of Health and Social
Care. Funding for this evaluation was also provided South West Academic Health
Sciences Network (SWAHSN). We would also like to extend a very grateful thanks
to all the healthcare professionals and patients who gave their precious time to
support this evaluation.
Contributors JC corresponded with partaking practices, collected data, analysed
data and compiled manuscript. BF input, validated and analysed data. HW
corresponded with partaking practices and collected data. JH corresponded with
partaking practices and collected data. WL supported the Interrupted Time Series
analysis. RBy aided study design and conception. MB corresponded with partaking
practices and data collection. LW helped with study design, data collection and
corresponded with partaking practices. RBl collected and analysed data for Hospital
Episode Statistics. LH corresponded with partaking practices and collected data.
HL designed and oversaw the study from inception to completion. All authors read,
contributed to and approved the manuscript.
Funding This research was supported by the National Institute for Health Research
(NIHR) Collaboration for Leadership in Applied Health Research and Care South
West Peninsula. Funding for this evaluation was provided by South West Academic
Health Sciences Network (SWAHSN). BF was supported by additional funding from
the University of Gothenburg Centre for Person-centred Care (GPCC)
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval Ethical clearance was obtained from the Plymouth University
Ethics Committees (FREC). All participants were given an information pack about
the study and gave informed consent.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All data relevant to the study are included in the article or
uploaded as supplementary information.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
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