Effect of the quality and outcomes framework on diabetes care in the UK

The care of patients with diabetes has improved over the last decade, but this does not seem to be a direct result of the quality and outcomes framework - the scheme that rewards UK general practices for delivering quality care.

The scheme in its present form may even lead to reduced levels of care for some patients, say researchers in a paper published on bmj.com.

The quality and outcomes framework was introduced in 2004 to improve standards of primary care by linking financial incentives to performance indicators for all general practitioners in the UK. The management of diabetes includes targets for controlling blood pressure, cholesterol and blood glucose levels. Payments are staged and are subject to minimum and maximum thresholds.

Since its introduction, a series of studies have suggested an improvement in the management of people with diabetes in primary care, but it is unclear whether this is a direct result of the scheme or reflects existing trends in response to other quality improvement strategies.

So researchers based at the Universities of Birmingham and Manchester assessed the proportion of patients meeting diabetes targets annually between 2001 and 2007 (three years prior to and following the introduction of the scheme). Their analysis included 147 general practices covering over one million patients across the UK.

They found significant improvements in all of the diabetes targets over the six year period, with consecutive annual improvements observed before the introduction of incentives.

However, these improvements in care appear to plateau after the introduction of the framework.

This could reflect the increasing difficulty of target attainment in poorly controlled patients, say the authors. However, it may also reflect the lack of further incentive after attainment of the upper payment thresholds (the ceiling effect).

If so, they suggest that upper thresholds may need to be removed or targets made more challenging if people are to benefit.

Another important finding was that up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes were not captured in the framework assessment. This needs to be addressed to reduce health inequalities, say the authors.

Our work and that of others highlights the potential unintended consequences of the scheme and raises concerns that the quality and outcomes framework may not have been as efficient in reducing inequalities in health in diabetes as was hoped, write the authors.

Although the management of patients with diabetes has improved since the late 1990s, the impact of the pay-for-performance initiative on care is not straightforward, they conclude.