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What does the COF mean for GPs?

Russell Finn looks at the financial effects of the commissioning outcomes framework on GPs.

COPD: there is a sizeable overlap of COF and QOF areas including COPD (Photograph: SPL)
COPD: there is a sizeable overlap of COF and QOF areas including COPD (Photograph: SPL)

The current consultation document on the commissioning outcomes framework (COF) indicators does give us some ideas about the possible funding structure of the new clinical commissioning group (CCG) budgets.

Following consultations about the new GMS contract, where income will be set in line with the costs associated with the diseases reported within its population, the entire CCG budget could rest on a similar formula.

This is also supported by the work done by the Nuffield Trust to develop a person-based resource allocation to predict the costs of their hospital care in the next financial year.

Quality premium
However, if this route is to be followed, the quality premium, which has been widely criticised because it might undermine patients' trust in GPs, would most likely be directly linked to the achievement of the CCG on the new indicators.

To have a COF that is not linked to a quality premium, however, would make the framework fairly toothless and would shy away from the NHS Commissioning Board's financial ability to bring CCGs to account for local commissioning decisions.

This funding method, however, will have a major impact on the funding of the ordinary GP practice.

Although there is a sizeable overlap of COF areas and QOF areas, such as cancer, COPD, chronic kidney disease, dementia and diabetes, if a CCG is to achieve its COF targets in other areas, the practices that it represents must also be working towards achieving those targets. The most likely way to achieve this would be to incentivise enhanced services in areas that directly correlate with the indicators under the COF.

One of the key areas of practice funding that could be hit is extended opening hours, which in most cases is classified as an enhanced service. More than likely, this service will become part of the main cost-based GMS contract, meaning that the extra funding available will be likely to disappear.

What is the COF?
  • Some 50 to 100 indicators are likely to be part of the commissioning outcomes framework (COF) at its launch in April 2013.
  • The COF will hold CCGs to account for local commissioning decisions and the local population's health.
  • The plans are controversial. How well CCGs meet these targets will determine whether they receive a quality premium payment for good commissioning, which could help expand GP services.
  • The GPC fears that the quality premium could create perverse incentives for GPs to cut NHS costs.


Nationalised framework
The problem with nationalising a framework of targets will no doubt lead to specific local issues being overlooked as it directs resources away from higher-funded areas.

This could mean that the ability of CCGs to fund local initiatives to combat diseases and social areas which are not covered by the COF could be squeezed. Such areas could include those that will now come directly under the public health outcomes framework (PHOF) and the adult social care outcomes framework (ASCOF).

Responsibility for funding services and reimbursements of practice expenditure under the PHOF and the ASCOF will now fall to local authority control, so services currently being run through GP surgeries could be removed and run under local authority led sites if councils think they can run services in a more efficient manner.

Another area of concern is if the funding structure becomes similar to the way the QOF is operated, which would see an end-loaded quality payment being paid to the CCG following the assessment of its COF indicators for the year.

As we have seen over recent years, the time it takes to receive the final payment has been increasing every year, which in turn has put cashflow pressure on the practices concerned.

If this were to be applied to the CCG level, the delays in filtering this income down to the practice level would considerably increase the timescales, which would further increase the financial pressure on individual practices.

This could also lead to problems with longer-term planning as budgets for future enhanced services would be directly affected by achievement in COF. This may result in funding in the underperforming areas being withdrawn once the data from the COF results has been analysed.

The impact that these changes have on poorly performing CCGs will also be more evident, owing to the fact that the CCGs may have little control over the achievement of some of the COF indicators, because the make-up of their population and the health service infrastructure would have been inherited from the PCT.

There is continued reliance on patient-reported outcome measures, some of which have been shown to be unreliable in the past. These will also still influence how well a CCG achieves its targets; however, in this case, the financial implication of these outcomes will be much greater and affect a large amount of practices.

In some extreme cases, practices in border regions may seek to switch to better performing CCGs with different population make-ups, in order to receive greater income from the better budget demographics.

  • Russell Finn is a client principle with specialist medical accountants Ramsay Brown & Partners www.ramsaybrown.co.uk

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