The National Audit Office has advised the Department of Health to renegotiate the Quality and Outcomes Framework (QoF) every year and allocate a percentage of QoF points for local negotiation.

In a 57 page report on the new contractual arrangements for GPs, NHS Pay Modernisation: New Contracts for General Practice Services in England, the NAO claims that the DH has no clear strategy for the QoF and focuses on indictors which are easy to measure.

The authors recommended that yearly negotiations on the QoF would help to develop a long term strategy and develop the QoF based on patient needs and in a transparent way.

It added: “The QOF strategy should be based more on outcomes and should also include an element of cost effectiveness. The value of QOF points should not be

made solely on the basis of an estimate of practice workload.”

The report also recommends that the DH should reduce the level of exceptions allowed under the QoF and that PCTs should ensure they compare exception reporting between practices to help inform their audit of the QoF scores. It said a proportion of QoF points should be allocated to PCTs or SHAs for local negotiation.

The NAO concluded that the QoF had improved the consistency of care but overall the new contract had not improved productivity, even when outputs have been adjusted to account for quality.

It recommended that any future changes to the contract should be piloted before they are implemented in the NHS.

Tim Burr, head of the NAO, commented: “There is no doubt that a new GP contract was needed and there are now 4,000 more GPs than five years ago. But in return for higher pay, we have yet to see real increases in productivity. The extra money flowing into practices has largely benefited GP partners rather than rewarding other important members of the practice team. Primary care trusts now need to deliver to patients the benefits that were expected in return for GPs increase in pay.”

However the BMA claimed that GPs are spending more time with their patients and that the work they do has become more complex since the introduction of the nGMS contract.

Dr Laurence Buckman, chairman of the BMA’s General Practitioner Committee, said: “The entire way GPs work has changed so it’s meaningless to talk about productivity in the way the NAO has done.”

The NAO report also looked at the effectiveness of PCT commissioning since the changes to GPs’ contract arrangements. It claimed that PCTs were not fully adapting their commissioning to meet local needed and recommended that PCTs improve the quality of the information they collect on local patient needs to enable them to commission services more effectively.

The report also claims that PCTs do not have effective performance management frameworks in place to monitor the delivery of GP services, in particularly essential services. The report added: “PCTs should adopt a performance management framework that monitors all aspects of their contracts and tackles poor performance.

Locally PCTs should clarify what standards of ‘essential services’ and level of quality they expect from practices for the global sum funding they receive. To determine probity of reporting of QOF measures by GP practices PCTs should develop a risk-based approach to monitoring.”

The NAO report includes figures on expenditure since the contract was introduced in 2004-5. It found that spending on information technology by PCTs exceeded the money allocated in 2004-5 and 2005-6, with £66m spent against a budget of £64m in the first year and £68m against an allocation of £65m in the second year. However in 2006-7 PCTs underspent their IT budget by £19m, spending only £65m of the £84m allocated.