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How the QOF fits with other target frameworks

Stephen Robinson explains the five outcomes frameworks that will monitor the NHS in England and how they will impact on GP practices

The DH wants England's health outcomes to match the world's best, and a series of frameworks and indicators will track the NHS's performance.

Care in England will face systematic scrutiny from April 2013 through national ‘frameworks’ to track population and patient outcomes. There will be three principal outcomes frameworks – one each for the NHS, public health and social care.

The NHS Outcomes Framework will be supported by the Commissioning Outcomes Framework, which will assess quality of care provision by clinical commissioning groups (CCGs), and the QOF, which assesses care in general practice. Addressing health inequalities will be a key priority across all five frameworks.

Ministers say this will make the NHS and local authorities more accountable and act as a ‘catalyst’ for quality improvement and culture change.

The indicators will resemble those found in the QOF, but they will be far wider reaching, covering everything from cancer survival to child poverty.

But controversy remains over the plans. The GPC has warned that plans to pay practices for how well they cut commissioning costs may destroy patients’ trust in GPs. The DH recently admitted that nationally set goals may distort local priorities. So how will the changes and each of the frameworks affect GPs and commissioners?


Launch: April 2004

Indicators (in 2012/13): 144 across four domains

Latest developments

About to enter its ninth year, the UK-wide QOF is being gradually reshaped into a tougher, more outward-looking framework to suit the DH agenda.

In 2012/13, many process measures and the first of the prescribing review indicators in the quality and productivity (QP) domain will go. In come a rise in lower and upper thresholds across dozens of indicators, A&E admissions targets, and a new focus on peripheral arterial disease and osteoporosis.

Plans for 2013/14 include aggresive new hypertension targets and referral to rehabilitation schemes for conditions such as COPD. In the longer term, the DH wants at least 15% of the framework dedicated to tackling public health goals, including obesity, smoking and alcohol.

Advantages: Attention on previously neglected areas such as osteoporosis.

Controversy: More emphasis on reducing hospital admissions, which may be outside GPs' control.

Why does it matter to GPs?: Signals much tougher QOF measures, with points harder to achieve and targets more aggressive



Launch: April 2011

Indicators (in 2012/13): 60 in five domains


The NHS is now under the microscope. The NHSOF has five 'domains' tracking patient outcomes: three for quality, and one each for patient experience and safety. This gives ministers a national overview of how well the NHS is caring for patients. The first of 60 planned indicators for 2012/13 shows that although fewer people aged under 75 are dying from respiratory disease compared with nearly a decade ago, deaths from liver disease have risen.

These outcomes will be used by the health secretary to hold the NHS Commissioning Board to account. The framework aims to drive quality improvements and reduce health inequalities, working alongside other frameworks with some overlap.

Advantages: National indicator of NHS quality of care; allows international comparison; can judge effects of NHS reforms.

Criticisms: Some indicators, such as employment of people with long-term conditions, may be outside NHS control; emphasis on patient-reported outcome measures (PROMs), deemed unreliable by the GPC.

Why does it matter to GPs?: Failure to improve NHS-wide outcomes could lead to greater scrutiny on primary care.



Launch: April 2011

Indicators (in 2012/13): 22


The ASCOF will be for social care what the NHSOF is for the NHS, measuring standards of care. It will help councils to share best practice. Its indicators overlap with the NHSOF, particularly on hospital discharge and mental health, to link health and social care.

GP commissioners will also need to work with local health and wellbeing boards to ensure commissioning priorities align with social care.

Advantages: Allows best practice to be shared between areas; aims to improve health and social care integration.

Controversy: None.

Why does it matter to GPs?: It employs measures of primary care such as GP patient surveys; it will affect CCGs' commissioning decisions.



Launch: April 2013

Indicators (in 2013/14): 50-100


Developed by the NHS Commissioning Board, the COF will hold CCGs to account for local commissioning decisions and their local population's health. The framework launches in April 2013 when CCGs take control of commissioning. NICE has published 120 draft indicators. These will measure areas of care from cancer survival rates to emergency admissions and many primary care-relevant measures, such as structured education for diabetes and antipsychotic prescribing.

Many indicators will align with national goals. In essence it is a localised version of the NHS Outcomes Framework.

General practice will be at the heart of the framework and GPs' computer systems will be mined for data to track outcomes achievement.

But 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 is opposed to the quality premium, fearing it could create perverse incentives for doctors to cut NHS costs.

Advantages: Can track impact of local commissioning decisions and aims to reduce health inequalities.

Controversy: Quality premium may undermine patients' trust.

Why does it matter to GPs?: It may affect practice income; it will be used to judge GP commissioning.



Launch: April 2013

Indicators (in 2013/14): 66 in four domains


When local authorities take responsibility for public health in April 2013, the PHOF will assess their efforts. Measures include reducing health inequalities between regions, improving 'healthy life expectancy' and overall life length.

It will track everything from hard clinical outcomes like cancer survival to social factors, such as child poverty. CCGs will site on health and wellbeing boards, which advise on health improvement. Their advice will be framed by the outcomes measured in the PHOF.

A DH review has said the plans could 'distort' focus away from local priorities

Advantages: Provides accountability for local authorities' public health spend.

Controversy: Health premium may peversely punish areas with highest need but hardest task.

Why does it matter to GPs?: Public health work by local authorities will affect the health of GPs' patients, how they access services and whether they self-care.


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