Professor Tim Stokes (left) and Nicola Bent outline the role of NICE in developing the quality and outcomes framework and highlight the changes to the 2011/2012 indicators


This article outlines the role of the National Institute for Health and Care Excellence (NICE) in the quality and outcomes framework (QOF) for general practice, the process used to develop new indicators, and the key changes for the clinical QOF indicator set for 2011/12.

Role of NICE in the QOF process

Overview
NICE has managed the new process for developing the QOF indicators since April 2009. This process has led to a number of significant changes to enable the QOF to deliver more rigorously developed indicators and act as a vehicle for quality improvement. NICE’s role is to manage the process of developing clinical and health improvement indicators for the QOF and to review the current indicator set.1 Key aspects of this process are:

  • ensuring consultation with individuals and stakeholder groups
  • publishing an annual ‘menu’ of new, evidence-based indicators
  • making recommendations on existing indicators, including those that should be retired.

It is important to emphasise that NICE does not decide which indicators are to be included in the QOF or what the set points and thresholds should be. These aspects will continue to be negotiated by NHS Employers on behalf of the Department of Health and the British Medical Association (BMA) General Practitioners’ Committee (GPC).1

NICE’s independent Primary Care QOF Indicator Advisory Committee is chaired by an experienced GP (Dr Colin Hunter). It comprises 30 members drawn from the four UK nations, and includes GPs and other primary care healthcare professionals, patients and carers, commissioners, pharmacists, and public health specialists. The Committee meets at least twice a year and meeting agendas and minutes are published on the NICE website.1 The core tasks of the Committee are to:1

  • prioritise suggestions for new clinical or public health topics
  • make recommendations for indicator development
  • consider the outcome of piloting and consultation and make final indicator recommendations
  • review information on the uptake of indicators in the QOF—this includes recommending whether any should be retired, considered for points
    and/or thresholds changes, or be subject to further assessment.

There are a number of key organisations that work closely with NICE to develop and pilot new QOF indicators and to review the existing QOF indicator set. NICE has commissioned the NICE External Contractor (NEC: a consortium of the National Primary Care Research and Development Unit, University of Manchester, York Health Economics Consortium, and the Royal College of General Practitioners) to develop indicators on clinical or health improvement topics as recommended by the Advisory Committee. NEC also provides an ongoing review of QOF indicators to make draft recommendations to the Committee on thresholds, continued incentivisation, and the evidence base.1

Development of new QOF indicators
The new NICE-managed QOF process (see Figure 1) is time consuming (it takes 24 months from start to being incorporated into the QOF), but has the advantages of being both rigorous and transparent. It uses an online topic suggestion facility on the NICE website to allow stakeholder organisations and individuals to suggest clinical and health improvement topics for consideration of potential QOF indicator development. These suggestions are then mapped by NICE against available NHS Evidence accredited sources—chiefly clinical guideline recommendations for primary care developed by NICE for England, Wales, and Northern Ireland, and by the Scottish Intercollegiate Guidelines Network (SIGN) for Scotland. NICE and SIGN guidelines are recognised internationally as being of high quality—they have rigorous development methods and consider clinical and cost effectiveness. The relevant clinical guideline recommendations and their accompanying evidence are then assessed against the Department of Health’s prioritisation framework for new QOF indicator topics.1

The NEC puts recommendations that are prioritised for QOF indicator development by the Committee through a formal indicator development process, which has two elements:

  • Formal consensus methods are used to reword the recommendations into indicators that are likely to be valid and can be extracted from GP clinical systems
  • The indicators are piloted in 30 representative practices across England and in a smaller number of practices in Wales, Scotland, and Northern Ireland.

During piloting, the indicators are tested for feasibility and reliability of data extraction across GP clinical systems, and data on workload is used to inform the cost-effectiveness analysis of each indicator. Interviews are also undertaken with general practice staff, including practice nurses, to determine if the indicators are acceptable to end users. In addition, NICE consults with stakeholders on the piloted indicators to allow them to comment on whether there are any barriers to implementation, potential unintended consequences, and whether implementation of the indicators may impact unevenly on different groups in the community.1

Both the results of piloting and consultation comments are reviewed by the QOF Advisory Committee, which then makes final recommendations on the proposed indicators to be published by NICE in its annual menu of indicators. These indicators are then considered by the negotiators for inclusion in the following year’s QOF.


Review and retirement of existing QOF indicators
Additionally, the QOF Advisory Committee has the important role of reviewing the existing QOF indicator set both in terms of any new research evidence that may mean they have to be altered or withdrawn, and with regard to whether they meet criteria for retirement (for example, indicators can be considered for retirement if they have stable and high levels of achievement).1 Retirement of existing indicators frees up QOF points so that new indicators can be introduced.

Figure 1: Summary of NICE QOF indicator development process

graph

Changes to the QOF for 2011–2012

NICE is responsible for the clinical and public health indicator set in the QOF and this section covers the key changes for 2011/12 that relate to this area (see Table 1). It is outside the remit of NICE to change the value of points or thresholds for indicators and these are not discussed. NICE has no involvement in decisions to retire organisational indicators (e.g. patient experience) or in the development of the new quality and productivity indicators (NB these are mentioned in this article for completeness).

Retirement of existing QOF indicators
A key principle of the NICE-led QOF is that indicators should be retired as appropriate. Twelve indicators (CHD5, CHD7, DM5, DM11, DM16, STROKE5, MH7, EP7, Information 4, Records 21, PE7, and PE8) have been retired releasing points to fund new and replacement indicators.2,3 The rationale behind retiring the coronary heart disease, diabetes, and stroke indicators is that they have stable and high levels of achievement and that they are ‘paired’ indicators—i.e. they are process measures (e.g. measurement of blood pressure [BP]/cholesterol) that have an associated intermediate outcome indicator (e.g. BP/cholesterol target) that is still in the QOF; therefore this means that the activity still needs to happen in order for the intermediate outcome QOF indicators to be met.

Replacement QOF indicators

Coronary heart disease
Patients with a history of myocardial infarction now need to be on angiotensin-converting enzyme inhibitors and statins as well as aspirin and beta blockers (CHD14).2,3 This is supported by evidence of clinical and cost effectiveness as presented in relevant NICE guidance.4,5

Diabetes
Key changes for the diabetes-indicator set relate to the glycated haemoglobin (HbA1c), BP targets, and diabetic foot care.2,3 The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) HbA1c level has been raised from 53 to 59 mmol/l (7.0% to 7.5% in Diabetes Control and Complications Trial values) (DM26). This indicator has been amended following advice from the NICE QOF Advisory Committee in response to concern that a lower level of 7.0% may have unintended consequences in terms of patient care because in order to achieve an average practice target of IFCC-HbA1c of 53 mmol/mol (7.0%), a clinician may need to aim for a IFCC-HbA1c below this in individual patients.

The three target levels for IFCC-HbA1c (59, 64, and 75 mmol/mol) in the QOF are designed to provide an incentive to improve glycaemic control across the distribution of values. The lower level may not be achievable or appropriate for all patients and the NICE guideline on the management of type 2 diabetes recommends against pursuing highly intensive management to levels below 48 mmol/mol (6.5%) in certain patient subgroups.6

The target indicator for BP in patients with diabetes (DM12) has been replaced by two separate indicators:2,3 DM31 sets a target of 140/80 mmHg as recommended by NICE guidance6 while a target of 150/90 mmHg (DM30) has been set for those patients who cannot achieve this tighter control, such as those with retinopathy, microalbuminuria, or cerebrovascular disease.2,3

Diabetic footcare (now DM29) is also given priority as foot risk needs to be assessed in addition to determining the presence or absence of peripheral pulses,2,3 and this indicator is in accordance with NICE guidance.7

Mental health
In the 2009/10 QOF, health promotion for people with serious mental illness was rewarded by an indicator that covered a large number of activities (a ‘bundled’ indicator). Thus MH9 addressed whether patients with schizophrenia, bipolar affective disorder, and other psychoses had received a recorded review in the preceding 15 months. This review required evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender, and health status. This indicator (MH9) has now been ‘unbundled’ in 2011/12 into six separate indicators (MH11, MH12, MH13, MH14, MH15, MH16) that define a physical health review (see Table 1, p.38).2,3 Thus alcohol consumption, body mass index, BP, cholesterol:high-density lipoprotein ratio, blood glucose, and cervical screening are separately assessed. The annual timeframe for these indicators is in line with NICE guidance.8

Depression
There has been a significant change of wording to DEP2. Instead of stating, ‘In those patients with a new diagnosis of depression … 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,’ the indicator has been changed to require an assessment of severity, ‘... at the time of diagnosis ...’ (see DEP4, Table 1, p.38).2,3 Assessment of severity in patients with depression is essential to decide on appropriate interventions and to improve the quality of care. An assessment of severity as close as possible to the time of diagnosis enables a discussion with the patient about relevant treatment and options, guided by the stepped-care model of depression described in NICE guidance.9


New QOF indicators

Epilepsy
The new epilepsy indicator EP9 addresses the specific needs of women of child-bearing age with epilepsy who are taking antiepileptic medication.2,3 The rationale for the indicator is that women with epilepsy on antiepileptic medication are at an increased risk of having a baby with a major congenital malformation.3 Timely advice on contraception, conception, and pregnancy is important and in accordance with NICE guidance.10

Learning disability
The new learning disability indicator, LD2, aims to improve health outcomes for people with Down’s syndrome through earlier detection and management of hypothyroidism. Children and adults with Down’s Syndrome are at increased risk of thyroid dysfunction, particularly hypothyroidism, compared with the general population, and incidence increases with age.2,3

Dementia
The new dementia indicator, DEM3, aims to improve health outcomes for people with suspected dementia by improving early detection and appropriate management of potentially reversible causes of dementia and to help exclude other diagnoses (e.g. delirium). These causes include metabolic and endocrine abnormalities (e.g. vitamin B12 and folate deficiency, hypothyroidism, diabetes, and disorders of calcium metabolism),2,3 and testing for these is in accordance with NICE guidance.11

Quality and productivity indicators
The 11 quality and productivity indicators are aimed at securing a more effective use of NHS resources through improvements in the quality of primary care by rewarding more clinically and cost-effective prescribing, reducing emergency admissions by providing care to patients through the use of alternative care pathways, and reducing hospital outpatient referrals.3

Table 1: Key changes to QOF 2011–12: replacement and new indicators2,3*
2011–12 QOF ID 2009–11
QOF ID
2011–2012 indicator wording Points Threshold
CHD14 CHD11 The percentage of patients with a history of myocardial infarction (from 1 April 2011) currently treated with an ACE inhibitor (or ARB if ACE intolerant), aspirin, or an alternative antiplatelet therapy, beta blocker and statin (unless a contraindication or side effects are recorded) 10 40–80%
DM26 DM23 The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months 17 40–50%
DM30 DM12 The percentage of patients with diabetes in whom the last blood pressure is 150/90 or less in the preceding 15 months 8 40–71%
DM31 The percentage of patients with diabetes in whom the last blood pressure is 140/80 or less in the preceding 15 months 10 40–60%
DM29 DM9 The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 15 months 4 40–90%
MH11 MH9 The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of alcohol consumption in the preceding 15 months 4 40–90%
MH12 The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of BMI in the preceding 15 months 4 40–90%
MH13 The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of blood pressure in the preceding 15 months 4 40–90%
MH14 The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder, and other psychoses who have a record of total cholesterol:HDL ratio in the preceding 15 months 5 40–80%
MH15 The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder, and other psychoses who have a record of blood glucose level in the preceding 15 months 5 40–80%
MH16 The percentage of patients (aged from 25 to 64 in England and Northern Ireland, from 20 to 60 in Scotland, and from 20 to 64 in Wales) with schizophrenia, bipolar affective disorder, and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years 5 40–80%
DEP4 DEP2 In those patients with a new diagnosis of depression, recorded between the preceding 1 April to 31 March, the percentage of patients who have had an assessment of severity at the time of diagnosis using an assessment tool validated for use in primary care 17 40–90%
EP9 The percentage of women under the age of 55 years who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception, and pregnancy in the preceding 15 months 3 40–90%
LD2 Percentage of patients on the learning disability register with Down's Syndrome aged 18 years and over who have a record of blood TSH in the preceding 15 months (excluding those who are on the thyroid disease register) 3 40–70%
DEM3 The percentage of patients with a new diagnosis of dementia from 1 April 2011 to have FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12, and folate levels recorded 6 months before or after entering on to the register 6 40–80%
*Not all changes to the indicators are shown in this table
ACE=angiotensin-converting enzyme inhibitor; ARB=angiotensin-II receptor blocker; IFCC= International Federation of Clinical Chemistry and Laboratory Medicine; HbA1c=glycated haemoglobin; DCCT= Diabetes Control and Complications Trial; BMI=body mass index; HDL=high-density lipoprotein; TSH=thyroid-stimulating hormone; FBC=full blood count

Conclusion

The 2011/12 QOF changes have resulted in the retirement of a number of existing indicators and the introduction of significant new clinical indicators that have been developed using the NICE process. These new indicators have the advantage of having being developed using a rigorous process that has involved both piloting and public consultation. It is hoped they will be well received by GPs and practice nurses.

  1. National Institute for Health and Care Excellence. Developing clinical and health improvement indicators for the quality and outcomes framework (QOF). Interim process guide. Manchester: NICE, 2009. Available at: www.nice.org.uk/media/742/32/QOFProcessGuide.pdf
  2. British Medical Association. NHS Employers. Summary of 2011/12 QOF indicator changes, points and thresholds. London: BMA, NHS Employers, 2011. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofguidance2011.jsp
  3. British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2011/12. London: BMA, NHS Employers, 2011. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofguidance2011.jsp
  4. National Institute for Health and Care Excellence. MI: secondary prevention. Secondary prevention in primary and secondary care for patients following a myocardial infarction. Clinical Guideline 48. London: NICE, 2007. Available at: www.nice.org.uk/guidance/CG48 nhs_accreditation_1cmyk.eps
  5. National Institute for Health and Care Excellence. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 67. London: NICE, 2008. Available at: www.nice.org.uk/guidance/CG67nhs_accreditation_1cmyk.eps
  6. National Institute for Health and Care Excellence. Type 2 diabetes: the management of type 2 diabetes. Clinical Guideline 87. London: NICE, 2009. Available at:
    www.nice.org.uk/CG87nhs_accreditation_1cmyk.eps
  7. National Institute for Clinical Excellence. Type 2 diabetes: prevention and management of foot problems. Clinical Guideline 10. London, NICE, 2004. Available at: www.nice.org.uk/guidance/CG10
  8. National Institute for Health and Care Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG82nhs_accreditation_1cmyk.eps
  9. National Institute for Health and Care Excellence. Depression: the treatment and management of depression in adults (update). Clinical Guideline 90. London: NICE, 2009.Available at: www.nice.org.uk/guidance/CG90nhs_accreditation_1cmyk.eps
  10. National Institute for Clinical Excellence. The diagnosis and management of epilepsies in adults and children in primary and secondary care. Clinical Guideline 20. London: NICE, 2004. Available at: www.nice.org.uk/guidance/CG20
  11. National Institute for Health and Care Excellence, Social Care Institute for Excellence. Dementia: Supporting people with dementia and their carers in health and social care. Clinical Guideline 42. London: NICE, 2006 (amended 2011). Available at: www.nice.org.uk/guidance/CG42 G