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How the QOF is evolving

Stephen Robinson highlights recent additions to the QOF in 2012/13 and looks at how it is likely to develop in the future.

Public health indicators related to smoking are proposed for the 2012/13 QOF
Public health indicators related to smoking are proposed for the 2012/13 QOF

How is QOF pay calculated?
Practices can earn a maximum of 1,000 points across domains for clinical, organisational, patient experience and additional services under the QOF 2012/13. Practices will earn on average £133.76 per point achieved, and in total this makes up about 25% of practice income. The values differ in Scotland, Wales and Northern Ireland. NICE estimates that the QOF costs the NHS about £1bn per year in England, or 15% of the primary care budget.

In the clinical domain, the pay-per-point value is modified by the prevalence of each disease among the population. A prevalence ‘factor’ is calculated for each disease area, which is a ratio of the practice prevalence compared to the national mean. The prevalence factor adjusts earnings so that practices with a high prevalence of disease are paid more because of the implied greater workload to earn points.

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Is the QOF effective?
Numerous studies have appraised the QOF since its inception in 2004/5. The consensus is that incentivising GPs to focus on a particular aspect of care leads to rapidly improved outcomes in that area.

A BMJ in 2011 found that the introduction of the QOF led to ‘substantial’ improvements in quality of care. However, the study found such improvements are specific to the incentivised activity and may be at the expense of non-incentivised care.

Research in the British Journal of General Practice also raised concerns that routine embedding of QOF depression questionnaires may encourage a ‘medicine by numbers’ approach, negatively affecting consultations. Another BMJ study from January 2011 suggested QOF indicators to manage patients’ BP have made ‘no discernible difference’ to improving care and patient outcomes.

However, there is little doubt that in the targeted areas, it has standardised high quality care across the country. Wiltshire GP Dr Gavin Jamie wrote in 2011 that the BMJ study shows the QOF does exactly what it is supposed to: incentivise care in particular areas, and nothing more. This is a fair summary of where QOF excels.

GPC chairman Dr Laurence Buckman has vigorously defended the framework. He argues it is more than just an incentive scheme because it supports previously unfunded work to reduce health inequalities. He says: ‘We expect the true gains will be seen in the long term as more evidence becomes available.’

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What’s new in 2012/13?
The big news about the 2012/13 GP contract was the continued freeze on pay. The only uplift in the whole GP contract came through a 0.5% rise, applied by raising the value of each point by £3. This means a practice with an average list size and average prevalence could earn an extra £3,250 for achieving the 1,000 QOF points available. This enabled practices to give staff earning less than £21,000 a year a pay rise of £250.

But practices are faced with harder targets to hit, after NICE recommended raising the thresholds of many indicators.

Payments per weighted patient through the global sum will rise by 8p, from £64.59 to £64.67, because around £1 million will be redirected from an osteoporosis directed enhanced service that has been scrapped.

Two indicators for CHD and AF were retired, along with prescribing indicators included in the 'quality and productivity' (QP) targets added to QOF in 2011/12. The indicators dropped were: CHD13, AF4, QP1, QP2, QP3, QP4 and QP5.

The retired QP prescribing indicators were replaced with targets for reducing A&E attendances, worth 31 points.

New clinical indicators came in for AF, smoking, peripheral arterial disease and osteoporosis. The value of indicators for BP, smoking, CKD and diabetes were cut by 26 points. Affected indicators are BP4, BP5, CKD2, DM2, DM22, smoking 3 and smoking 4.

All indicators with lower thresholds currently 40-90% have been raised to 50-90% and lower thresholds raised to 45% for indicators currently with an upper threshold between 70-85%.

Upper thresholds have changed for indicators CHD6, CHD10, PP1, PP2, HF4, STROKE6, STROKE8, DM17, DM31, COPD10 and CKD5, and lower and upper threshold changes for BP5, MH10 and DEM2.

As a result, practice workload is set to rise this year as 'retired' indicators must still be delivered, points are stripped from indicators that remain, and thresholds for achieving QOF points are pushed up.

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Why is public health entering the QOF?
Health secretary Andrew Lansley’s public health White Paper in December 2010 outlined how 15% of QOF funding should contribute to public health and primary prevention indicators from 2013.

GP negotiators accepted new QOF indicators - for smoking3 and smoking4 - as part of this shift. The full 15% target must be delived by April 2013.

The current proposed public health indicators are relatively benign. But GPs might expect more controversial targets to be proposed in the near future as the public health drive becomes more urgent.

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How has the ‘Nicholson Challenge’ affected the QOF?
Whereas the public health agenda merely tweaks the QOF, the DH Quality, Innovation, Productivity and Prevention (QIPP) programme heralds a far broader change. Primary care must contribute a 4% saving to help meet the £20 billion efficiency savings – the so-called ‘Nicholson Challenge’.

The new quality and productivity domain, first announced in March 2011, is the means to this end. At the time, Mr Lansley said: ‘Every penny saved will be invested back into patient care, including to directly improve further the quality of patient services in primary care.’ Despite being inspired by the England-only QIPP initiative, the domain, like the rest of the QOF, applies in all four UK countries.

The QP domain has been refreshed for 2012/13 by dropping the prescribing targets and adding in requirements to reduce A&E admissions.

That all of these plans will be determined locally is a new direction for the QOF and fits with the government’s localism agenda.

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What’s coming in 2013/14?
GP negotiators will start to thrash out the deal for the next GP contract in the autumn. They can use a number of indicators recommended by NICE to inform their discussions.

 

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The future of the QOF
Numerous government and political agendas are likely to shape the QOF over the coming years. The government will pressure NICE to recommend more public health measures and lean on negotiators to accept indicators to help meet efficiency targets.

Beyond these, NICE’s advisory team at the University of Manchester is examining so-called ‘tightly linked measures’, or TLMs. TLMs encourage GPs to pursue care processes that are more strongly linked to important outcomes than current QOF indicators, taking into account the severity of a patient’s condition.

The closest example in the current QOF is CHD11 – the percentage of patients with a history of MI (diagnosed after 1 April 2003) who are currently treated with an ACE inhibitor or an ARB.

More complicated TLMs ‘involve the measurement of a process of care and an intermediate or downstream outcome’, according to Professor Helen Lester of the University of Manchester team working with NICE to develop the QOF.

In effect, a TLM indicator focuses not only on the achievement of the target, but on the process of care itself.

Dr Lester says such measures do not yet exist in the QOF but have been used in the US Department of Veterans Affairs.

She says that they have many benefits over existing indicators: they do not penalise GPs who care for sicker patients, and could help to address health inequalities and identify patients at high risk of poor outcomes downstream. She says they had been shown to improve clinical control of conditions because of their specificity and may help to ‘decrease an incentive to treat in an overly aggressive manner’. In addition, they align with DoH aims to focus on care outcomes.

An example of a more complicated TLM, for hypertension, would begin to reward care when any of the following conditions are met:

  •     Index BP less than 150/90mmHg
  •     On three or more moderate-dose BP medications
  •     Appropriate clinical action within 90 days
  •     Increase in BP medication class
  •     Repeat BP less than 150/90mmHg

However, tracking which patients are being assessed by which criteria requires ‘sophisticated’ IT infrastructure and more resources, she warned.

The committee has agreed to pilot one or two such indicators for the QOF, describing it as ‘an opportunity to move QOF on’. Following the June 2012 QOF advisory board meeting, these indicators are still under consideration.

The introduction of TLMs and the other significant changes discussed above all suggest the QOF will undergo a radical departure from the current framework in the next few years.

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