Lack of evidence to support QOF incentives for assessing depression severity using tools in primary care

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The quality and outcomes framework was set up in 2004 to incentivise aspects of clinical practice within general practice in the UK.

Two standards which are incentivised in depression are DEP4 (the percentage of patients who have had assessment of severity at diagnosis using a tool validated for use in primary care (PHQ-9, BDI-II, HADS-D)) and DEP5 (the percentage of patients who have had assessment of severity at diagnosis and a further assessment of severity between 4-12 weeks later using one of aforementioned tools).

But what is the evidence that tools such as DEP4 and DEP5 actually improve patient care?  A new systematic review in the British Journal of General Practice provides quantitative and qualitative answers to this question.

The key findings of the review were –

  • Uncertainty with regards to any improvement in health outcomes
  • GPs perceived there may be unintended consequences for the nature of consultations, the doctor-patient relationship and clinical autonomy.


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Some GPs felt that the instruments may adversely impact the doctor-patient relationship.

The review was based on whether the use of a structured tool improves outcomes and what both patients’ and clinicians’ experiences of the assessment were (looking for unintended consequences). These two questions were considered for both assessment at diagnosis (DEP4) and assessment at follow up between 4-12 weeks later (DEP5).

A literature search of a number of databases was carried out and after screening and eligibility, 10 reports of 8 studies were included. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system was used to evaluate the studies looking at effectiveness.


  • The authors found very low quality evidence to suggest that there is an association between using structured tools or GP judgement to assess severity at diagnosis and treatment rates and referral. No evidence was found to suggest using a structured tool at diagnosis improved outcomes .
  • Patients felt that using a tool at diagnosis was an “efficient addition” to the clinicians’ judgement.
  • However, clinical judgement was favoured over structured assessment by GPs and concern was expressed that the incentive introduced by QOF to incorporate tools at diagnosis has a negative effect on the doctor-patient relationship and holistic practice.
  • On using a tool at follow up, very low quality evidence suggested there were increased rates of remission and response when a tool was used but management was not affected.
  • Patients felt that they could use the follow up assessment to monitor their progress.
  • Clinicians had concerns as to whether adapting the questionnaires for different patient groups affected the validity of the tools (both at diagnosis and follow up).


“Any estimate of the effect of structured assessment of depression severity in UK general practice is uncertain. GPs consider routine use of questionnaires as incentivised by the QOF has unintended consequences, which could adversely affect patient care.”

This review has found an absence of good quality evidence to support the use of structured tools in depression as set out in the QOF.

The authors also point out the discrepancy between NICE guidance – which recommends clinicians consider using a tool, and the QOF.

Clearly assessment of severity at diagnosis and follow up ensures the patient receives the most appropriate care. This could be done either with a structured tool or within a consultation using clinical judgement. With the incentive provided by the QOF, the questionnaires are likely to be the default option and potentially negative unintended consequences have been flagged up in this study.


National Institute for Health and Social Care Excellence (NICE) 2013. About the Quality and Outcomes Framework (QOF).

National Institute for Health and Social Care Excellence (NICE) 2009. Depression in adults (update) (CG90).


Shaw EJ, Sutcliffe D, Lacey T, Stokes T. Assessing depression severity using the UK Quality and Outcomes Framework depression indicators: a systematic review. Br J Gen Pract 2013; DOI:10.3399/bjgp13X667169.  [PubMed abstract]


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