Exception reporting in the Quality and Outcomes Framework: views of practice staff - a qualitative study

Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a 'gaming' mechanism.

To explore GP and practice staff views and experiences of exception reporting in the QOF.

Qualitative semi-structured interviews.

Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.

Semi-structured interviews, analysed using open explorative thematic coding.

Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an 'exception to the rule' that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by 'other' practices. Only two GPs admitted to occasional inappropriate exception reporting.

Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism.