The nGMS contract’s quality and outcomes framework (QOF) was always going to be a dynamic structure to enable practices to be paid to deliver high quality care.
The BMA’s General Practitioners Committee (GPC) has taken the view that any criticism of the quality of care that GPs deliver would be answered by the success of the QOF – and so it has proved. In fact, GPs have succeeded beyond all expectations. The Government, however, wanted to find ways to recoup what it saw as overpayment, and that is the context in which the 2005 QOF review was begun.
Background to the review
The review was intended to identify markers that had gained or lost evidence, matters that had changed their legal status and items that the NHS no longer wished to purchase. Also, as part of the review, the Government wanted to ensure that QOF2 delivered the ‘value for money’ that it perceived had been absent with QOF1.
As usual, politicians want ‘must-dos’ whereas the profession wants evidence-based medicine. QOF1 was based almost entirely on evidence or good practice, and this has been strengthened with QOF2. Most GPs will be satisfied with the results of our efforts because we have tried to ensure that the work that most GPs actually do is recognised. GP focus groups run by the independent advisors to the QOF review have confirmed that our approach is the right one.
Given this background, it was important to answer the value for money argument once and for all. The GPC and our negotiating partners, NHS Employers, agreed that we would do this, not by cheapening the QOF, but through adjustments to it. These have been achieved as part of the overall contract review, which is not yet complete.
The QOF is almost finished, and we believe that only the definitive guidance remains to be completed.That is being prepared now and will be released as soon as it is ready. The Read codes have been determined and the software suppliers alerted, so when the rest of the contract review is concluded the NHS will know what the QOF review has delivered.
For the moment, this outline is all I can offer as the full details will be determined by the final outcome of negotiations and shaped by adjustments to the guidance.
The new QOF indicators
|DEM 1||The practice can produce a register of patients diagnosed with dementia||5|
||The percentage of patients diagnosed with dementia whose care has been reviewed in the preceding 15 months
|DEP 1||The percentage of patients with diabetes and/or heart disease for whom case finding for depression has been undertaken on one occasion during the previous 15 months using the two standard screening questions||8||40-90%|
|DEP 2||In those patients with a new diagnosis of depression, recorded between the preceding 1 April and 31 March, the percentage of patients who have had an assessment of severity at the outset of treatment using an assessment tool validated for use in primary care||25||40-90%|
|Chronic kidney disease|
|ChKD 1||The practice can produce a register of patients aged 18 years and over with ChKD (US National Kidney Foundation: Stage 3-5 ChKD)||6|
|ChKD 2||The percentage of patients on the ChKD register whose notes have a record of blood pressure in the previous 15 months||6||40-90%|
|ChKD 3||The percentage of patients on the ChKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 mmHg or less||11||40-70%|
|ChKD 4||The percentage of patients on the ChKD register who are treated with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side-effects are recorded)||4||40-80%|
|AF 1||The practice can produce a register of patients with atrial fibrillation||5|
|AF 2|| The percentage of patients with atrial fibrillation diagnosed from 1 April 2006 with ECG or specialist confirmed diagnosis
|AF 3||The percentage of patients with atrial fibrillation who are currently treated with anti-coagulant drug therapy or an anti-platelet drug therapy||15||40-90%|
|PC 1||The practice has a complete register of all patients in need of palliative/supportive care||3|
|PC 2||The practice has regular (at least 3-monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed||3|
|MH 6||The percentage of patients on the register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate||6||To be confirmed|
|MH 7|| The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who
do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance
|Obesity 1||The practice can produce a register of patients aged 16 years and over with a BMI greater than or equal to 30 in the past 15 months||8|
|LD 1||The practice can produce a register of patients with learning disabilities||4|
|Records 21||Ethnic origin is recorded for 100% of new registrations from 1 April 2006 1||1|
Changes to the QOF
What is almost certain is that the changes to QOF2 will be as set out in the Tables on above. Points will have the same value in 2006 as in 2005 and taking part will remain voluntary. A word of warning, however: practices should not attempt to gear up for these new indicators before the relevant guidance is issued.
In England, the 50 extra points for access have been moved into national direct enhanced services, as the profession has always wanted. Final decisions on this are still awaited in the other three home countries.
We will not be producing ‘efficiency savings’ on the QOF again and we will be paid for offering high quality evolving care to our patients. In other words, we will carry on with QOF2 just as we did with QOF1 – delivering the best care we can. No one will be able to say that it is ‘money for old rope’.
The QOF negotiators from both teams (most of whom are GPs) have been meeting for months, and in Spring 2005 they appointed the University of Birmingham and the RCGP to act as independent assessors of all the primary care evidence, both old and new.
We invited anyone who wished to submit evidence to do so by 30 May 2005, and we received 514 submissions, of varying quality, from Government departments, academic institutions, learned societies, patient groups and practices. We screened them and extracted those that had sufficient evidence and that the NHS could afford.
Inevitably, some worthy submissions were excluded because they were just too expensive,and many GPs will feel that the end result ignores some important areas.
Why the QOF does not recognise all GP work
It remains true that much of what GPs do goes unrecognised in the QOF. That is because there is a large evidence gap for much of our work; it can be hard to define and often does not involve specific diagnoses. Care that is holistic and addresses the patient’s health alongside personal and social factors cannot easily be measured.
The QOF rewards us for some of the evidence-based aspects of practice and it certainly does not cover all the worthwhile work we do for our patients – but just because it isn’t in the QOF, doesn’t mean it has no value. Moreover, the reward for this unobserved work is contained in the global sum, just as it was recognised in the old ‘Red Book’ capitation fee.
Redistribution of points
After extensive consideration, we have removed 138 points that were offered under the non-clinical indicators of QOF1.This was agreed as the profession’s contribution to the cuts demanded by the Treasury. These points consisted of 80 of the 100 holistic points, practice quality points and some points for markers that were seen as developmental in QOF1, such as ensuring that patient notes were legible and kept in order.
These points are seen as having done their job and are no longer being monitored under the QOF. It was felt that they could be put to better use elsewhere without damaging practice incomes.
Some 28 points have been redistributed. QMAS showed that six clinical indicators – in the CHD, hypertension, diabetes and COPD domains – were particularly hard to deliver, and each has been increased by one point.
An indicator has been added for summarising, to enable practices to gain points for this very expensive, ongoing task. Both the patient questionnaire and 10-minute consultations attract more points. Significant event reviews, too, are worth more points and it has been made easier to achieve them.
All these changes will be welcome because they recognise that some of QOF1 was very challenging as well as being expensive to do well.
Most of the domain registers have lost a point because they are largely established and now merely require maintenance. Most of the other clinical indicators are unchanged, although some have been modified to make them clearer, easier or more sensible.
For example, the smoking markers attract the same number of points as previously, but are gathered in one place to prevent multiple recording in each domain. None of these changes will concern the average practice, which is already participating in delivering these domains.
New indicators and domains
Of most interest are the 138 points’ worth of new indicators and new clinical domains. Under QOF2, not only will the mental health indicators make much more sense, but we will also be rewarded for our clinical work in:
- Dementia – by providing annual reviews of care.
- Depression – by assessing the severity of new cases.
- Chronic kidney disease – patients with this condition will be easily identified when the new estimated glomerular filtration rate test becomes a routine part of U&E testing and practices are automatically sent the results.
- Atrial fibrillation – by prescribing aspirin or warfarin.
- Palliative care – through carrying out regular reviews with the practice team.
We will be rewarded for setting up a register of patients with learning disabilities, and if we wish we can create registers of new patients’ ethnicities.This is widely regarded as good practice although many GPs and patients may be uncomfortable with it.We can also keep a register of the obese, although we do not have to do anything beyond knowing who is very fat.The Government wants us to identify these people, but at least they are not going to set our pay by how many we make thin.
QMAS reports in England, and their equivalents in the other nations, have shown that most practices achieved well above 25% in QOF1, so we have agreed to raise the payment threshold from 25% to 40% for most indicators in QOF2. Most upper limits have been set at 90% unless evidence suggests that it is unattainable or inappropriate. In fact, since most practices achieved more than 70%, and the majority of these got more than 90%, this change should also cause little distress.
So what will all these changes mean in practice? QOF2 will have 655 clinical points, 181 organisational points and 108 points for patient experience as well as 36 additional service points and 20 holistic points.
This altered emphasis on clinical activity will be supported by most GPs. Greater recognition of our current workload will also vindicate our belief that we already do much more high-quality, evidence-based work than we have been credited with.
When you encounter QOF2 you will instantly see why the changes were made and how you can enter into the ‘new work’ with little practice upheaval – at least I hope so, as we made a great effort to ensure that. If we all do very well again – and I believe we will – it will be because we deserve to.