Significant variations in the way the Quality and Outcomes Framework is managed mean patients and taxpayers may be losing out, the Audit Commission has found.

The watchdog examined how primary care trusts check that QoF payments are properly made and that the right patients are receiving the right services under the scheme, which pays out around £1 billion a year to GP practices in England.

The review, Paying GPs to Improve Quality, found significant variation in the approach to all aspects of managing and monitoring the QoF by PCTs and wide variations in exception rates among practices.

Andy McKeon, managing director of health at the Audit Commission, said: “Audit isn’t just about counting the pennies.

"It’s about ensuring that patients get the services they are entitled to and that taxpayers’ money is spent in the best possible way. Out report shows a wide variation in how PCTs approach this, ranging from poor to good."

He said that as the NHS was reorganised robust audit would be crucial to ensure payments were being made properly and fairly and that patients were getting the benefits intended.

He also warned that any role for GP commissioning consortia in QoF would have to be carefully managed so conflicts of interest were avoided.

The Audit Commission review of 12 PCTs found that exception reporting – which allows GPs to exclude patients from targets that are not appropriate for them – varied between different PCTs from 3.81% to 7.65%.

There were greater variations within PCTs. One PCT included in the study had exception reporting rates ranging from 2.5% to 15.1%.

The Audit Commission said some variation could be expected because of factors such as geography, deprivation or the particular circumstances of a practice and its patients.

However, it said PCTs should take suitable action to ensure patients are only exception-reported for legitimate reasons.

Despite this, it added that there was also no evidence to suggest any systematic ‘gaming’ by GP practices to improve their scores and increase their payments by over-reporting exceptions.

The Audit Commission also found that PCTs took varying approaches to making sure that payments made to GP practices were correct and justified.

It found differing attitudes towards the reasons for making practice visits, the frequency of visits, the quality and training of assessors, and the use of benchmarking data.

Some PCTs suggested the purpose of QoF visits was to help GP practices maximise their income. Most PCTs found it difficult to prove a link between high QoF scores and improved outcomes for patients.

“We found PCTs where there was no risk assessment of individual practices to inform either the timing or the focus of the visit," the report said. One PCT only carried out visits to practices that asked for them.

The Audit Commission said lack of independence sometimes added to lack of clarity about the scope and purpose of QoF visits, since most PCTs used GPs from within their own area as clinical assessors.

It commented: “While this is understandable and practical, especially in less urban areas, it may not result in a rigorous regime.”

Some PCTs used data and indicators to review GP practices’ performance, but other PCTs carried out little or no benchmarking.

“Some PCTs were aware of GP practices within their area that were ‘outliers’ in terms of achievement under QoF or exception rates and had examined and understood the reasons for this: other PCTs were not," the report said.

Auditors also found some PCTs had concerns about GPs exception reporting all patients because of where they lived – for example in a nursing home – rather than because of their clinical condition.

The report said: “PCTs need to be clear whether they support GP practices exception-reporting in this way and if not take action.”

The Audit Commission said it believed good practice should include annual QoF visits or visits every three years based on a robust and systematic risk assessment involving the use of benchmarking.

It said job descriptions should be used to create a shared understanding of the assessor role and that assessors should preferably not be local GPs.

It also wanted to see greater scrutiny of ‘block exceptions’ and supported explanations for high exception rates.