The quality and outcomes framework of the nGMS contract, introduced in April 2004, is currently undergoing review to incorporate the latest evidence. The revised version will come into effect in April 2006.

All the domains and all the indicators will be reviewed. The current points available for each indicator will be scrutinised to check whether they reflect the actual amount of work done. New indicators may also be added.

“We will be looking to see whether the evidence has changed and also whether things can be done better, for example is the separation between asthma and COPD about right?” said Dr Laurence Buckman, co-chair of the QOF review, speaking at the Guidelines in Practice annual conference, in London, earlier this month.

“The evidence for asthma seems to be changing by the minute. Major studies published in the last couple of months will clearly influence the asthma indicators,” added Dr Buckman, deputy chairman of the BMA General Practitioners Committee.

The nGMS contract is the first in the world to pay practices for delivering quality care based on evidence that interventions by practices would make a material difference to patients.

The QOF was never intended to cover everything, as Dr Buckman explained.

Dr Laurence Buckman,
Deputy Chairman of the
BMA GPC and co-chair
of the QOF review: “"Just
because it [a condition]
isn't in the QOF doesn't
mean we don't look
after these people. It just
means that the evidence
base for primary care
intervention that is
ungameable and can be
computerised is not

“The QOF was intended to pay GPs and their practices for work already done, if they were delivering quality of care, or to encourage them to take an evidence-based approach in the delivery of care to those aspects of medicine that could be quantified in a way that was acceptable to the people that pay us,” said Dr Buckman.

“The QOF has been engineered so that it can’t be gamed, for example, you can’t label someone as having angina if they haven’t got it,” added Dr Buckman who was a member of the original team who drew up the QOF.

The QOF was developed by trawling the evidence base in a wide variety of disease areas in primary care.

The evidence had to satisfy certain criteria. It had to be published and peer-reviewed, applicable to primary care and preferably come from the UK.

The indicators had to be measurable and be capable of being recorded on a computer system, and not be gameable. They also needed to cover areas that the profession thought was worthwhile and was a legitimate priority.

“Just because it [a condition] isn’t in the QOF doesn’t mean we don’t look after these people. It just means that the evidence base for primary care intervention that is reproducible, ungameable and can be computerised is not there,” said Dr Buckman.

“Guidelines inform the QOF.The review will look at all the major published guidelines to see how they can be mined for use within the QOF,” explained Dr Buckman.

Any suggestions for changes to the QOF must be submitted, along with the supporting evidence, to the review team at the University of Birmingham by 30 May.

Submissions must explain: why an indicator or domain should change, the prevalence of the condition, and whether it is a priority in all four countries.The other questions that need to be addressed are: whether the health profession would support the proposed change, whether it would benefit patients and reduce morbidity and mortality, and whether the benefits would outweigh workload and cost.

“I think the QOF is going to change but probably not very much. What’s there will probably stay with changes within the points and the indicators, and a couple of diseases may alter in some way,” said Dr Buckman.

Two of the key recommendations of the BTS/SIGN asthma guideline, establishing an accurate diagnosis and carrying out regular review, are reflected in the asthma indicators.

“The thinking behind the indicator on establishing an objective diagnosis comes from the BTS/SIGN guideline,” said Dr Hilary Pinnock, a member of the guideline development group. Asthma indicator 2 says the diagnosis must have been confirmed by spirometry or peak flow.

“The QOF rewards points for doing a single peak flow measurement but the guideline states that variability needs to be demonstrated and this cannot be achieved with one reading,” explained Dr Pinnock, a member of the GPIAG.

“Asthma can be missed by taking just one reading,” she emphasised.

Dr Hilary Pinnock, GP
Whitstable, member of
the GPIAG and
member of the
BTS/SIGN asthma
guideline steering
group: “"So far the
practice has achieved a
review rate of nearly
80% with around a
third of patients opting
for phone


In order to obtain maximum points for the regular review indicator 70% of patients must have had a review in the past 15 months. However, patients are often reluctant to attend for review.

One way round this problem is to offer telephone reviews, said Dr Pinnock.

A study she took part in, carried out in four general practices, found that when patients were randomised to face to face or telephone reviews, only half attended for surgery review compared with three quarters who took up the offer of a telephone review. Phone reviews took half the time, 11 minutes compared with 22 minutes, and resulted in a saving of £4 per review.

Dr Pinnock’s practice in Whitstable has been adopting this approach for the past year. Patients are offered a booked telephone appointment or a clinic slot for their review.

Young children and patients who have had frequent exacerbations and hospital admissions are encouraged to attend the practice for review.

So far the practice has achieved a review rate of nearly 80% with around a third of patients opting for phone consultations.

The GPIAG is submitting evidence to the QOF review on suggested changes to the asthma indicators.

The indicators for COPD are based largely on recommendations from the BTS COPD guidelines, published in 1997.

However, in the past year or so three more evidence-based guidelines have been published in this area, including a national guideline from NICE which updates the BTS guideline and has been endorsed by the BTS.

Recommendations from these guidelines are likely to influence the ongoing development of the clinical indicators, said Wrexham GP Dr Peter Saul.

He speculated that pulmonary rehabilitation for COPD patients, recommended by recent guidelines, might well be included in a revision of the indicators, along with pneumococcal immunisation and monitoring BMI.

Producing an accurate register of patients with COPD is difficult as it is often hard to distinguish between COPD and asthma and some patients may have both, said Dr Saul.

“Guidelines are the tools to develop management strategies for the conditions covered by the indicators,” said Dr Saul, hospital practitioner in asthma and allergy, Countess of Chester Hospital.

“The challenge of the QOF is not just to ensure that we improve identification of patients but to take it a step further and ensure we improve patient care,” he added.

The second annual Guidelines in Practice conference “Implementing national guidelines and the nGMS contract: asthma, COPD and hypertension” took place at the Royal Society of Medicine, London, on 12 May.

Guidelines in Practice, May 2005, Volume 8(5)
© 2005 MGP Ltd
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