Dr Tim Stokes explains how the wide-ranging changes in the 2014/15 QOF came about and explores some possible implications for patients and general practitioners
This article summarises the role of NICE in the quality and outcomes framework (QOF) for general practice, and discusses the key changes in the clinical QOF indicator set for 2014/15 in England.1,2 The agreed QOF contract for 2014/15 in Wales3 Scotland,4 and Northern Ireland5 differs from that in England.
NICE has managed the process for developing QOF indicators since April 2009. This process has led to a number of significant changes to enable QOF to deliver more rigorously developed indicators (one key development is that indicators are piloted prior to their adoption) and act as a vehicle for quality improvement. The role of NICE is to manage the process of developing clinical and health improvement indicators for the QOF and to review the current QOF indicator set.6,7 Key aspects of this process are to:
- ensure consultation with individuals and stakeholder groups
- publish an annual ‘menu’ of new, evidence-based indicators
- make recommendations about 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 are the subject of separate negotiation by NHS Employers (on behalf of NHS England) and the General Practitioners Committee of the British Medical Association. The changes to QOF for 2014/15 represent the most significant amendments made under NICE’s stewardship; the background to them is given below.
Background to the 2014/15 QOF changes
In August 2013, in accordance with agreed process,6 NICE made recommendations to negotiators on six new indicators for QOF. These included the incentivisation of confirming hypertension using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), as recommended in the recent NICE clinical guideline on hypertension.8 In August 2013, however, NHS England formally asked NICE to review the QOF clinical and public health indicator set to determine which indicators would be the most important to retain in the event that the number of indicators in QOF were reduced, with a view to using NICE’s review to inform the QOF negotiations for 2014/15.9 NICE’s QOF Indicator Advisory Committee (hereinafter referred to as ‘the NICE advisory committee’) met in September 2013 to review all the current QOF clinical and public health indicators against an explicit decision-making framework (e.g. strength of evidence supporting each indicator; whether working as intended; workload for practices). The NICE advisory committee considered that it was important to retain the majoritiy of the clinical indicator set and identified a minority (23%, 26 out of 111) of indicators, chiefly those in the public health additional services domain (cervical screening; child health surveillance; maternity and sexual health), that were less important to retain. In the negotiation process, however, more radical changes were made to QOF than were advised by NICE, and in November 2013, NHS England announced a set of major changes to QOF for 2014/15.1 A similar set of changes have been made in Scotland, Wales,3,4 and Northern Ireland5.
Changes to QOF for 2014/15
The QOF negotiators’ stated approach for 2014/15 was to streamline the QOF and prioritise the retention of key indicators.2 Therefore, no new indicators developed by NICE have been introduced and the key change is to retire a significant number of clinical and public health indicators. The rationale for this is to ‘promote a stronger focus on addressing the holistic needs of people with multiple health and care needs’.1
The key changes to QOF in the clinical and public health domains for 2014/15 are: the retirement of 24 indicators from the clinical domain, releasing 185 points, and the retirement of six indicators from the public health domain, releasing 33 points (see Table 1). In addition, the retirement of the patient experience indictor PE001 will release 33 points and the retirement of nine indicators from the quality and productivity domain will release a further 100 points. The resource from 238 points will be transferred into global sum. The resource released from the remaining 103 points will see 100 points used to fund a new enhanced service aimed at avoiding unplanned admissions and delivering proactive case management for vulnerable people, and three points transferred to the learning disabilities enhanced service.10
Overall, there has been a significant change to a number of clinical and public health areas.10 The negotiators have gone beyond the advice they received from NICE and the majority of retirements (53%, 16 out of 30) are indicators recently developed using the NICE process (2011/12 QOF or later), which the NICE advisory committee felt that it was important to retain (see Table 1). The key changes, and their implications for quality improvement in general practice, are summarised on page 3.
|2013-14 QOF ID||2013-14 Indicator wording||Year introduced into QOF||NICE recommendation prior to retirement||Points Value|
|AF002||The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHADS2 risk stratification scoring system in the preceding 12 months (excluding those whose previous CHADS2 score is greater than 1)||2013–14||Important to retain||10|
|CHD003||The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less||2004–05||Important to retain||17|
|HYP003||The percentage of patients aged 79 or under with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 140/90 mmHg or less||2013–14||Important to retain||50|
|HYP004||The percentage of patients with hypertension aged 16 or over who have not attained the age of 75 in whom there is an annual assessment of physical activity, using GPPAQ, in the preceding 12 months||2013–14||Less important to retain||5|
|HYP005||The percentage of patients with hypertension aged 16 or over who have not attained the age of 75 who score ‘less than active’ on GPPAQ in the preceding 12 months, who also have a record of a brief intervention in the preceding 12 months||2013–14||Less important to retain||6|
|PAD003||The percentage of patients with peripheral arterial disease in whom the last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less||2012–13||Important to retain||3|
|STIA004||The percentage of patients with stroke or transient ischaemic attack (TIA) who have a record of total cholesterol in the preceding 12 months||2004–05||Important to retain||2|
|STIA005||The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less||2004–05||Important to retain||5|
|DM005||The percentage of patients with diabetes, on the register, who have a record of an albumin:creatinine ratio test in the preceding 12 months||2004–05 (revised wording 2013–14)||Important to retain||3|
|DM011||The percentage of patients with diabetes, on the register, who have a record of retinal screening in the preceding 12 months||2004–05||Important to retain||5|
|DM013||The percentage of patients with diabetes, on the register, who have a record of a dietary review by a suitably competent professional in the preceding 12 months||2013–14||Important to retain||3|
|DM015||The percentage of male patients with diabetes, on the register, with a record of being asked about erectile dysfunction in the preceding 12 months||2013–14||Less important to retain||4|
|DM016||The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 12 months||2013–14||Less important to retain||6|
|THY001||The contractor establishes and maintains a register of patients with hypothyroidism who are currently treated with levothyroxine||2004–05||Less important to retain||1|
|THY002||The percentage of patients with hypothyroidism, on the register, with thyroid function tests recorded in the preceding 12 months||2004–05||Less important to retain||6|
|DEP001||The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who have had a bio-psychosocial assessment by the point of diagnosis. The completion of the assessment is to be recorded on the same day as the diagnosis is recorded||2013–14||Less important to retain||21|
|MH004||The percentage of patients aged 40 or over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol:hdl ratio in the preceding 12 months||2011–12||Important to retain||5|
|MH005||The percentage of patients aged 40 or over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose or HbA1c in the preceding 12 months||2011–12||Important to retain||5|
|MH006||The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 12 months||2011–12||Important to retain||4|
|EP002||The percentage of patients aged 18 or over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the preceding 12 months||2004–05||Important to retain||6|
|EP003||The percentage of women aged 18 or over and who have not attained the age of 55 who are taking antiepileptic drugs who have a record of information and counseling about contraception, conception and pregnancy in the preceding 12 months||2011–12||Important to retain||3|
|LD002||The percentage of patients on the learning disability register with Down’s Syndrome aged 18 or over who have a record of blood TSH in the preceding 12 months (excluding those who are on the thyroid disease register)||2011–12||Less important to retain||3 (transferred to Learning disabilities Enhanced Services)|
|RA003||The percentage of patients with rheumatoid arthritis aged 30 or over and who have not attained the age of 85 who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 12 months||2013–14||Important to retain||7|
|RA004||The percentage of patients aged 50 or over and who have not attained the age of 91 with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 24 months||2013–14||Important to retain||5|
|CVD-PP002||The percentage of patients diagnosed with hypertension (diagnosed on or after 1 April 2009) who are given lifestyle advice in the preceding 12 months for: smoking cessation, safe alcohol consumption and healthy diet||2009–10||Less important to retain||5|
|SMOK001||The percentage of patients aged 15 or over whose notes record smoking status in the preceding 24 months||2004-05||Less important to retain||11|
|CS003||The contractor ensures there is a system for informing all women of the results of cervical screening tests||2004–05||Less important to retain||2|
|CHS001||Child development checks are offered at intervals that are consistent with national guidelines and policy agreed with NHS England||2004–05||Less important to retain||6|
|MAT001||Antenatal care and screening are offered according to current local guidelines agreed with NHS England||2004–05||Less important to retain||6|
|CON002||The percentage of women, on the register, prescribed an oral or patch contraceptive method in the preceding 12 months who have also received information from the contractor about long acting reversible methods of contraception in the preceding 12 months||2009–10||Less important to retain||3|
|Total points retired||218|
Retirement of existing QOF clinical indicators
There are two significant retirements. The first is the retirement of an intermediate outcome indicator—the tighter blood pressure (BP) target (140/90 mm/Hg) (HYP003)—which was only introduced into QOF in 2013/14. This means that practices are now incentivised to manage BP against the target (HYP002) that has been in QOF since 2004/05 (and with 20 points as opposed to the 50 allocated to HYP003). The likelihood of this change improving the quality of care for patients with hypertension must be questioned: the need for tighter BP control has a strong evidence base, is recommended in NICE Clinical Guideline 127 on hypertension,8 and the older QOF indicator may not have improved hypertension-related clinical outcomes.11 It is also noteworthy that the negotiators have not introduced into QOF an important new indicator that promotes the correct diagnosis of hypertension through the use of ABPM or HBPM.8
The second retirement is of two indicators (HYP004, HYP005), again only introduced into QOF in 2013/14, which sought to encourage greater physical activity through the use of a structured questionnaire (General Practice Physical Activity Questionnaire [GPPAQ]) and a brief intervention. Although these indicators were piloted before their introduction into QOF,7 they have since been the subject of criticism for promoting a ‘tick box’ approach to physical activity; also, there is no measure of the quality of the delivered brief intervention,9 so withdrawal of these indicators are unlikely to have an adverse effect on patient outcomes.
Lipid managent in people with established cardiovascular disease
It is important that people with established cardiovascular disease (CVD) receive statin therapy and that their lipid levels are managed.12 Since 2004/05, QOF has addressed this issue with an intermediate outcome indicator of a lipid target level of 5 mmol/l or less for people with coronary heart disease, stroke, and peripheral arterial disease (the latter since 2012/13). The retirement of CHD003, PAD003, and STIA005 means that lipid management in this group of patients is no longer incentivised. In contrast, this intermediate outcome indicator remains for people with diabetes (DM004). The NICE advisory committee recommended that all these indicators were important to retain.9
Two of the retirements in the diabetes indicator set have the potential to adversely affect the care of people with diabetes: the removal of retinal screening (DM011, introduced 2004/05) and the removal of the need for patients to have had a dietary review by a suitably competent professional (DM013, introduced 2013/14).9 It is less clear whether the retirement of the erectile dysfunction diabetes indicators (DM015 and DM016), only introduced in 2013/14, will lead to adverse health outcomes; there is an argument that assessing erectile dysfunction may not need to be done annually, as was incentivised by QOF.9 It is also unlikely that the retirement of DM005 (record of albumin:creatinine ratio [ACR] test) will lead to adverse outcomes, as the action (doing an ACR test) is a requirement for the linked indicator, DM006, which is retained (treating those with microalbuminuria with an angiotensin-converting enzyme inhibitor [ACE] inhibitor).
The key set of retirements for mental health relate to the management of physical health problems of people with serious mental illness (SMI, e.g. schizophrenia, bipolar disorder). With the exception of the blood pressure indicator (MH003), all the other indicators that promote the management of the physical healthcare needs of these patients have been retired (MH004 to MH006). People with SMI are a disadvantaged group and there have to be concerns about the impact these retirements will have on the physical health needs of these patients and whether they will receive the attention they require in primary care.
In 2013/14, the QOF depression indicators, which promoted the use of formal assessment questionnaires, were retired due to their poor evidence base, and also because of evidence of unintended consequences with their use.13 Two replacement indicators were introduced. Of these, one has now been retired (DEP001, the need to do a bio-psychosocial assessment), with the NICE advisory committee considering that this indicator added to workload and that its removal would be unlikely to lead to adverse effects on care.9
The removal of THY001 and THY002 means that, for the first time, a clinical area in QOF has been removed. These indicators have, however, been in QOF since its inception, so it is likely that conducting thyroid function tests in patients with hypothyroidism has now become a routine part of clinical practice and that this will continue, even though the QOF indicators have been retired.
Epilepsy has been in QOF since its inception in 2004/05 and there is evidence that the epilepsy QOF indicators have led to improved health outcomes for patients.14 Epilepsy has also been the only QOF domain with a health outcome indicator (patient seizure-free for past 12 months). It is, therefore, disappointing that only the register indicator for epilepsy (EP001) now remains, with the retirement of both EP003 (seizure-free for the past 12 months) and EP004 (information and counselling for women about contraception, conception, and pregnancy).
Retirement of existing QOF public health indicators
There has been a streamlining of the existing public health indicators. In particular, QOF no longer incentivises child health surveillance (CHS001), antenatal care and screening (MAT001), systems for informing women of the results of cervical screening tests (CS003), or advice to women using contraception about long-acting reversible methods (CON002). These retirements are in accordance with the NICE advisory committee’s assessment that these indicators were less important to retain.
The changes to the QOF clinical indicator set for 2014/15 are wide-ranging. General practitioners may be pleased that some clinical QOF indicators carrying significant workload, and which appear to have a limited effect on clinical outcomes (e.g. HYP004, HYP005), have been removed. From a quality improvement perspective, however, there have to be concerns. Although recent research has shown that the retirement of eight QOF indicators in 2006 and 2011/12 has led to stable levels of performance in the retired areas,15 it should be noted that the care in seven of the eight withdrawn indicators remains incentivised in QOF through other related indicators. The retirements this time round break new ground, since many of the indicators being retired are ‘stand-alone’; therefore all financial incentives in relation to them have now been removed,16 so there is no financial incentive to monitor the physical health of people with SMI, manage lipid levels in people with established CVD, or conduct any care processes for people with epilepsy. In addition, reduced blood pressure targets for people with hypertension have now been set. It will therefore be important that the effects of these retired indicators are monitored. Overall, there seems little logic as to which indicators have been retired and which have been retained, particularly as the majority of the retired indicators have only recently been introduced into QOF; one can hypothesise that these are less likely, therefore, to have become embedded into routine practice. It will also be interesting to see if the negotiators decide to introduce any new NICE-developed indicators in 2015/16.
About the author
Tim Stokes was Consultant Clinical Adviser to NICE on its QOF work programme 2009–2013. The views expressed here are his own and do not represent the views of NICE or its QOF Indicator Advisory Committee.
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- BMA website. General practice contract changes 2014–2015. Welsh GP contract 2014–2015. bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/general-practice-contract/contract-agreement-wales/wales-qof-changes (accessed 2 April 2014)
- BMA website. General practice contract changes 2014–2015. Scottish GMS contract 2014–2015. bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/general-practice-contract/contract-agreement-scotland (accessed 2 April 2014).
- BMA website. General practice contract changes 2014–2015. Northern Ireland GP contract 2014–2015. bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/general-practice-contract/contract-northern-ireland (accessed 2 April 2014).
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- NICE. Hypertension: clinical management of primary hypertension in adults. Clinical Guideline 127. London: NICE, 2011. Available at: publications.nice.org.uk/hypertension-cg127
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- Serumaga B Ross-Degnan D, Avery A et al. Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study. BMJ 2011; 342: d108.
- NICE. 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: publications.nice.org.uk/lipid-modification-cg67
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- Kontopantelis E, Springate D, Reeves D et al. Withdrawing performance indicators: retrospective analysis of general practice performance under UK quality and outcomes framework. BMJ 2014; 348: g330.
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