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How the QOF will change in 2013

The DH plans for the GMS contract in April will see the biggest overhaul of QOF since its inception and lead to differences in the framework between the four countries.

The GPC is concerned about changes to hypertension indicators (Picture: JH Lancy)
The GPC is concerned about changes to hypertension indicators (Picture: JH Lancy)

The DH has announced the outcome of a consultation on its plans for the 2013/14 GP contract, and has chosen to adopt nearly all the proposals set out in December.

As a result, the huge package of changes to the QOF will now go ahead from 1 April, and may mean practices see large swings in QOF funding as the changes take effect.

In January, the BMA claimed the plans could cut £31,000 from practice income.

The changes to the QOF will represent the framework’s biggest overhaul since it was first established.

Despite concessions by the department over five QOF indicators, the DH has adopted almost all NICE's proposed indicators, as well as far tougher thresholds and the scrapping of the organisational domain, the money from which will be used for four controversial new directed enhanced services (DESs).

The DH will defer two proposed indicators - for referral to cardiac and pulmonary rehabilitation - until April 2014 'to allow more time for GPs to work with clinical commissioning groups to ensure the necessary referral services are in place'.

The DH also agreed to phase in higher thresholds for two physical activity QOF targets, and to increase the share of QOF points for these and a BP control measure 'to recognise the initial impact of these indicators on practice workload'.

The DH plans will set thresholds for achieving maximum points at the level of the best-performing 25% of practices.

Some clinical areas' upper thresholds will rise to 100% (CHD14 and HF3) - meaning practices will need to treat or refer every single patient with the condition to earn all QOF points in that area. It may force practices to exception report more patients.

The GPC believes the introduction of tougher thresholds will lose practices £11,000.

Other changes include a cut in the time period allowed for annual reviews, from 15 to 12 months, a new public health domain and changes to the way practice list size, which is used to calculate QOF income, is formulated. The DH also wants to retain the quality and productivity (QP) indicators in 2013/14.

The full specification for the QOF will be available shortly.

QOF changes at a glance (England)
  • Raise upper thresholds for existing indicators to reflect the current achievement of the 75th centile of practices. This will be phased, with this increase to threshold levels applied to 20 indicators in 2013/14 and remaining indicators in 2014/15.
  • Set up a public health domain to include relevant indicators from the clinical, additional services and organisational domains.
  • Retain for a further year the quality and productivity (QP) indicators.
  • Remove the remaining organisational indicators.
  • Reduce the time period for most indicators from 15 months to 12 months.
  • Reform the list size weighting.

Enhanced services

Money raised by axing the QOF indicators will fund new directed enhanced services for England covering:

  • the identification and case management of patients identified as seriously ill or at risk of emergency hospital admission
  • undertaking a proactive approach to the timely assessment of patients who may be at risk of dementia (based on opportunistic offer of assessment for dementia to at-risk patients who are aged 60 and over with CVD, stroke, peripheral vascular disease or diabetes; patients aged 40 and over with Down’s syndrome and other patients aged 50 and over with learning disabilities; and patients with long term neurological conditions which have a known neurodegenerative element, for example, Parkinson’s disease
  • enabling patients to use electronic communications for booking of appointments and repeat prescriptions
  • undertaking preparatory work in 2013/14 to support the subsequent introduction of remote care monitoring arrangements for patients with long term but relatively stable conditions (in 2014/15).
More details on the DESs will be made available shortly.

Unworkable targets

A GPC analysis of the DH's plans earlier this year suggested many new indicators backed by NICE are 'unworkable and impractical'. The GPC said the new indicators would cause unfeasibly high workload for practices and hinder good patient care.

In the case of a proposed new hypertension indicator, nearly nine million GPPAQ physical activity questionnaires would need to be carried out across the UK each year, the GPC said, 'which would clearly have significant knock on effects to the rest of the service without any discernible benefit'.

The forthcoming target to aggressively pursue a BP target of 140/90 among patients under 79 risks increasing polypharmacy and possible hypotension, GP leaders said.

Extra training for GPs and diabetic nurses may be required to meet targets for diabetes dietary reviews, which may add 'significant extra costs' to practices when, the GPC argued, GPs already have the necessary skills. It also expressed concerns about indicators to be retired that cover work still needing to be funded, including CKD2, EPILEPSY6 and BP4.

However, many of the GPC's concerns over the plans appear to have been rejected by the DH.

These included concerns over unnecessary extra training requirements for diabetes dietary review, questions about erectile dysfunction among patients with diabetes, and the retirement of several indicators including CKD2, EPILEPSY 6 and BP4.

Scotland

GP practices in Scotland will avoid many of the changes above after GPC Scotland agreed a deal with the Scottish government for 2013/14.

The Scottish deal involves a ‘modest increase’ in thresholds for 10 clinical QOF indicators. There will be no upper threshold indicator above 90% in 2013/14.

Although the majority of NICE clinical QOF recommendations will be implemented ‘due to recognition that the clinical QOF should be broadly the same across the UK’, substantial changes have been made, GPC Scotland has said.

Certain indicators will not be introduced, exception reporting will apply to some indicators where it was not previously proposed that it would and GPC Scotland will work with the Scottish government to agree alteration to UK QOF guidance to ensure it is suitable for Scotland. Full details of these changes can be found here.

The deal will also see £10,000 of the money practices are paid for the organisational domain moved to core pay. The organisational points will be allocated as follows:

  • 37 points relate to clinical QOF changes - the indicators previously associated with these points will no longer be incentivised and therefore practices are not required to continue this work. 
  • The new NICE QOF indicators that are not introduced in Scotland free up 11 points which will be used to introduce key elements of the patient safety programme in general practice. 
  • 23 points will be transferred to a new medicines management domain. 
  • 17 points will be transferred to a new public health domain.
  • 33 points will remain for patient experience but no longer within the organisational domain.
  • 77 points will be transferred to the global sum. For each practice this will be an average of the previous three years achievement for these points.

Wales

GP leaders in Wales have also agreed a deal that will also see slightly different changes to the QOF.

Under the plans all NICE suggestions for the QOF will be introduced, however there will be some variation from England.

QOF thresholds will still rise over the next two years, but they will be lower than those set out in the UK deal. Practices would be asked to match the performance of the top half of practices in the previous year to earn maximum points, rather than match the top 25% as proposed by the UK government.

The threshold for hypertension indicator HYP3 will not be changed, the two new indicators relating to annual exercise questionnaires (HYP4, HYP5) will not be introduced and guidance on dietary advice for diabetics (DM13) will stipulate that no extra training is required for GPs and practice nurses.

The move from a 15-month to a 12-month window for delivering most indicators will not take place in Wales.

Practices in Wales will also retain 59 of the 154.5 organisational indicators that the UK government plans to axe. Some of these points will be used to fund the new QOF indicators and a new risk profiling QP domain.

Money from the QP targets for avoiding A&E visits will be reinvested into practices’ global sum equivalent payments, so it will be received by all practices not just the 40% who do not rely on MPIG top-ups. The first referral and emergency admission elements of the QP indicators remain unchanged.

Northern Ireland

Details of any changes to the Northern Ireland QOF are expected soon.

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