Dr Nigel Watson outlines how the QOF quality and productivity indicators aim to improve efficiency through clinician engagement and clinical pathway redesign

Commissioning is a term that is used widely within the NHS. The concept of clinically led commissioning has been used more widely over the past couple of years. It can be defined as: ‘A continual process of analysing the needs of a community, designing pathways of care, then specifying and procuring services that will deliver and improve agreed health and social outcomes, within the resources available.1

Practices are responsible for a group of registered patients and are very experienced at developing and implementing population-based clinical services. However, when asked, many GPs do not believe that they are directly involved in commissioning, yet they are directly responsible for approximately 70%–80% of NHS expenditure because, on behalf of an individual patient, they prescribe, refer, admit, and coordinate care—in effect the GP commissions care on behalf of the individual patient.

The decision by the Government to promote clinically led commissioning and the pivotal role that GPs are expected to play are therefore no surprise. This remains one of the cornerstones of the Health and Social Care Bill.2 It is well recognised that commissioning will have a limited impact if the wider clinical community is not engaged and they do not believe that they have some ownership of the commissioning process.

I have yet to meet a single clinician in the NHS who, if asked, cannot name instantly several services or clinical pathways that they believe are ineffective or of poor quality, and could be improved with some clinical advice. This does not mean that all clinicians should reduce their clinical commitment immediately and become part-time commissioners, but it does mean that strong clinical leaders are needed to lead the commissioning process, and that this must be supported by good managers and the wider profession.

Practice-based commissioning (PBC)3 was introduced to try and achieve greater clinical engagement and ownership of commissioning, but all too often the work was neither practice based nor related to commissioning. Excellent results were achieved in some parts of the country, but in many others, PBC had little or no impact.

There was much discussion in 2009/10 about the future of the quality and outcomes framework (QOF), particularly regarding the organisational indicators. Incentive schemes for PBC were funding practices to carry out tasks as defined by primary care organisations, but which rarely resulted in the effective engagement of front-line clinicians. Prescribing incentive schemes were the most successful in achieving effective clinical engagement and demonstrating practice ownership, and they often resulted in a change of behaviour. Such schemes include switching from expensive to more cost-effective medications (e.g. angiotensin converting-enzyme inhibitors, bisphosphonates) or reviewing how patients obtain blood-glucose testing strips.4

It was therefore decided by the Department of Health to incentivise commissioning through the QOF.5 Three key areas in which GPs have a degree of control in terms of clinical behaviour are:

  • prescribing
  • elective referrals
  • emergency admissions.

It has been demonstrated through experience that peer pressure and review, when conducted in a ‘safe’ environment, can change clinical behaviour and is far more successful than an edict being issued from an external body. General practitioners working together in a group of six or more practices could review data for individual practices and by doing so would be able to identify clinical areas where efficiency and effectiveness could be improved by redesigning clinical pathways.

Quality and productivity in the QOF

For the first time, the QOF changes for 2011/12 included a number of indicators that related directly to commissioning (see Table 1). The new quality and productivity (QP) indicators are worth 96.5 points and each point is worth £130.51 for the average practice.6 Therefore for the average practice of around 6000 patients, the new QOF indicators on commissioning are worth £12,500 if all points are achieved.

The QP indicators cover:

  • prescribing (QP1–5)
  • outpatient referrals (QP6–8)
  • emergency admissions (QP9–11).

This article discusses indicators QP6–Q11; the prescribing indicators, QP1–QP5, are not covered as I believe GPs are well aware of all the issues as a result of prescribing incentive schemes and these indicators are due to be removed in the 2012/13 QOF.

Table 1: QOF indicators relating to mental health4
No. Indicator Amendments Points Payment stages
QP1 The practice conducts an internal review of their prescribing to assess whether it is clinically appropriate and cost effective, agrees with the PCO three areas for improvement, and produces a draft plan for each area no later than 30 June 2011

New indicator

QP2 The practice participates in an external peer review of prescribing with a group of practices and agrees plans for three prescribing areas for improvement firstly with the group and then with the PCO no later than 30 September 2011 New indicator 7  
QP3 The percentage of prescriptions complying with the agreed plan for the first improvement area as a percentage of all prescriptions in that improvement area during the period 1 January 2012 to 31 March 2012 New indicator 5 Locally determined*
QP4 The percentage of prescriptions complying with the agreed plan for the second improvement area as a percentage of all prescriptions in that improvement area during the period 1 January 2012 to 31 March 2012 New indicator 5 Locally determined*
QP5 The percentage of prescriptions complying with the agreed plan for the third improvement area as a percentage of all prescriptions in that improvement area during the period 1 January 2012 to 31 March 2012 New indicator 5 Locally determined*
QP6 The practice meets internally to review the data on secondary care outpatient referrals provided by the PCO New indicator 5  
QP7 The practice participates in an external peer review with a group of practices to compare its secondary care outpatient referral data either with practices in the group of practices or with practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO New indicator 5  
QP8 The practice engages with the development of and follows three agreed care pathways for improving the management of patients in the primary care setting (unless in individual cases they justify clinical reasons for not doing this) to avoid inappropriate outpatient referrals and produces a report of the action taken to the PCO no later than 31 March 2012 New indicator 11  
QP9 The practice meets internally to review the data on emergency admissions provided by the PCO New indicator 5  
QP10 The practice participates in an external peer review with a group of practices to compare its data on emergency admissions either with practices in the group of practices or practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO New indicator 15  
QP11 The practice engages with the development of and follows three agreed care pathways (unless in individual cases they justify clinical reasons for not doing this) in the management and treatment of patients in aiming to avoid emergency admissions and produces a report of the action taken to the PCO no later than 31 March 2012 New indicator 27.5  
*Payment stages to be determined locally according to the method set out in the indicator guidance with 20 percentage points between upper and lower thresholds Total points 96.5

Outpatient referrals

Practices have found that the following specialties have a significant number of referrals: cardiology; dermatology; ear, nose, and throat; gynaecology; ophthalmology; orthopaedics; and urology.7 Individual practices and groups of practices have examined each speciality to find out which sub-groups have the most frequent referrals and examples of these are given below:

  • Ophthalmology:
    • Opticians identifying a cataract or suspected glaucoma account for 60%–80% of referrals in this speciality
  • Orthopaedics:
    • Hip and knee arthritis are common reasons for referral, but so is carpal tunnel syndrome and back pain
  • Urology:
    • Lower urinary tract symptoms in males aged over 50 years are common reasons for referrals.

A group of GP practices has identified cataracts as a common reason for referral, with a high conversion rate to operation. But how often does a GP assess the need for an operation prior to referral and are they aware of local criteria or simply identifying the fact that a cataract has been detected and asking the ophthalmologist to make that assessment?

Using cataracts as a practice example, GPs should, prior to referral, perform an assessment and consider the following:

  • The impact on daily living (e.g. driving, reading)
  • Has a threshold been agreed locally (e.g. visual acuity)?
  • Have exceptional circumstances been agreed?
  • Is the patient willing to undergo an operation and aware of the benefits and the risks?

A potential pathway could be:

  1. Threshold for referral agreed with ophthalmologists, GPs, and opticians.
  2. Optician’s report sent to GP, which confirms that the patient meets the threshold for surgery.
  3. GP discusses impact on daily living—agrees with patient that referral for surgery is required, and patient is ready, willing, and able.
  4. Community based clinic reviews all referrals and has the ability to directly list patients in local hospital.

In some areas, a pre-defined letter has been adopted by all practices to assist in this process and an example is shown in Box 1.

Carpal tunnel syndrome
If primary clinicians are asked to discuss carpal tunnel syndrome (CTS) and describe which investigations and treatments are carried out and offered, there will almost certainly be significant variation between individuals.

A possible pathway for CTS includes:8

  • Conservative measures:
    • Non-steroidal anti-inflammatory drugs
    • Wrist splints, with approximate cost of £15
    • Steroid injections
  • Consider referral if:
    • conservative measures failed
    • there is evidence of neurological deficient (i.e. sensory blunting of weakness of thenar abduction)
    • duration of symptoms ?6 months.

An agreed letter could be used where appropriate (see Box 2).

The new pathways will have little or no impact unless they are agreed locally and there is effective engagement and ownership by all clinicians. This all takes time and commitment.

Box 1: Example referral letter for cataracts
Dear Colleague,

«PATIENT_Locality» «PATIENT_Town»

This patient has been seen by an optician and assessed as having a cataract, which is appropriate for surgical intervention.

I have discussed this with the patient and confirmed that they are willing to attend to discuss surgical intervention.

The patient has a visual acuity in keeping with the guidelines for the threshold for surgical intervention:

  • Binocular visual acuity of 6/10 or worse for drivers, or binocular visual acuity of 6/12 or worse for non-drivers
  • Or reduced to 6/18 or worse irrespective of the acuity of the other eye
  • Or the patient wishes to/is required to drive and does not meet Driving and Licensing Authority eyesight requirements.

I have included a copy of the opticians GOS18 report.

Box 2: Example referral letter for carpal tunnel syndrome
Dear Colleague,

«PATIENT_Locality» «PATIENT_Town»

Thank you for seeing this patient, who has typical symptoms of a carpal tunnel syndrome.

An assessment was carried out initially to exclude any atypical symptoms, namely: no numbness or tingling of the hand; tingling or numbness in the middle finger or seen eminence; paraesthesia in the hands after coughing or neck movements; sensory loss above the elbow.

The symptoms have now been present for more than 6 months and the following conservative measures have been tried:

  • Non-steroidal anti-inflammatory drugs
  • Wrist splints for 6 weeks
  • Injecting into the carpal tunnel.

In addition there is no evidence of neurological deficiency (i.e. sensory blunting or weakness of thenar abduction).

Surgery has been discussed as an option for treatment and the patient would like to discuss this further with you.

Emergency admissions

It has been estimated that practices are directly responsible for approximately 30%–40% of all emergency admissions. The remainder of admissions come from accident and emergency, ambulance services, and out of hours (OOH). As practices have little or no control over 60%–70% of emergency admissions, one could therefore argue that indicators in this area should not be included as part of the QOF. Individually, the impact of GPs on emergency admissions may be small, but practices working together as commissioners may have a significant impact. Areas that could be considered include:

  • OOH admissions
  • frequent attendees at accident and emergency
  • frequent 999 callers
  • frail elderly.

Out-of-hours admission
Many people would consider that the threshold for admission during the OOH period is different from ‘in hours’. Is this true or simply anecdotal? Are patients who are receiving ‘end-of-life care’ admitted at inappropriate times (particularly those who are residents at nursing homes)?

Practices should review admissions during the OOH period and consider the above questions; the outcome of these discussions can then form part of future strategic planning for a locality or commissioning group.

Frequent attendees at accident and emergency
When a patient is seen in accident and emergency, a practice will often receive a written summary of the reason for attendance and the action taken. The majority of attendances are appropriate, but some are not. Two published studies present very different views, with a large disparity in the suggested number of patients who attend accident and emergency inappropriately (6.7%9 versus over 60%10). Both of these studies are dated and probably need to be repeated.

A practice can examine a specific cohort of patients—for example, individuals who have had two or more accident and emergency admissions—and review if their attendance was appropriate. The practice should then take action to prevent future inappropriate admissions.

Frequent 999 calls
The ambulance service has sophisticated software that is able to identify frequent callers from a specific geographical area and timescale. Reviewing people who have had three or more calls during a 6-month period may detect individuals who are already known to have high clinical need, and also identify those with poor control of their condition or frank abuse of the system. Discussion and subsequent follow up of these issues at a local level and with primary care trusts can lead to the development of new pathways of care.

Frail elderly
A situation that is commonly faced by a GP is an elderly patient who lives on their own and who has had a fall, may have become confused, or has ‘gone off their legs’. This group is often referred to as ‘the frail elderly’. All too often these patients are admitted to hospital because the health service does not provide an alternative to admission.

Pathways for reducing emergency admissions
Possible pathways include:

  • Community rapid response:
    • This is a team of community nurses and therapists who work to prevent the admission of complex patients (those who have a combination of healthcare and social care needs or who may have more than one long-term condition) to hospital. The team can be contacted to assist in the management of the frail elderly and active management of patients who have frequent falls
  • Community geriatricians
    • They can work with GPs and nursing teams in the community to help prevent avoidable admissions and assist in addressing the health needs of people who are at high risk of admissions.
  • Acute assessment as an alternative to admission:
    • An outpatient appointment costs between £100 and £300 and an acute admission is in excess of £1000, but all too often the former arrangement is too far into the future, and the patient requires urgent assessment rather than an acute admission. The development of an assessment unit that can assess, investigate, and potentially discharge patients is a possible alternative to admission.

QOF changes for 2012/13

Prescribing is an important area in terms of the costs of providing healthcare. Currently the prescribing budget for GP practices is £8 billion or approximately 8% of the total NHS budget. Prescribing is included in the 2011/12 QOF as part of the QP indicators and medicines management. In addition, many PCTs have a prescribing incentive scheme, which is part of the commissioning local enhanced scheme (LES). The Department of Health has therefore decided to simplify this for the 2012/13 QOF by removing the prescribing component of the QP indicators and replacing it with indicators relating to accident and emergency attendance.11


In a time of budget cuts and financial pressure there is a real danger that the health service will become a victim of ‘slash and burn’, with services being cut to save money, with no alternative option for patients. To avoid this, limited resources need to be used effectively in order to achieve this, it is essential that all clinicians are involved in commissioning and delivering care to patient populations rather than individual patients, hence the drive to incentivised clinical engagement through the commissioning process.

  • The QP indicators provide GP commissioners with a fantastic opportunity to involve and incentivise local practices in pathway design and redesign
  • For 2012, the QOF QP indicators reward participation in pathway development and adherence, but are not dependent on actual final numbers of referrals or attendances
  • Indicators QP1–5 will not be included in the QOF next year so GP commissioners will need to consider whether to establish a separate prescribing incentive scheme
  • GP commissioners should work with PCT primary care commissioning departments to agree local requirements for releasing money and ensure for probity that it is the PCT that signs these off and not just the shadow CCG
  • Agreement with the LMC over these markers and the actions required from practices to meet them is also highly advised
  • For 2012, a review of accident and emergency attendances through a practice audit could help commissioners design new pathways, review current services, and inform the future commissioning of the 111 service.
  1. Royal College of General Practitioners. Briefing guide: commissioning. Engaging service users, carers, and other stakeholders in commissioning and developing services. London: RCGP, 2011. Available at: commissioning.rcgp.org.uk/wp-content/uploads/2011/08/RCGP-LEROY-Briefing-Guide-v5.pdf
  2. House of Commons. Health and Social Care Bill. Stationery Office, 2011. Available at: www.publications.parliament.uk/pa/cm201011/cmbills/132/11132.pdf
  3. The King's Fund website. Practice-based commissioning. www.kingsfund.org.uk/current_projects/practicebased_commissioning/ (accessed 30 November 2011).
  4. NHS Suffolk website. Prescribing incentive scheme. www.suffolkextranet.nhs.uk/Home/MedicinesManagement/GPArea/PrescribingIncentiveScheme.aspx (accessed 30 November 2011).
  5. 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.jspQOF
  6. NHS Employers website. Contract changes 2011/12. www.nhsemployers.org/PayAndContracts/GeneralMedicalServices
    (accessed 30 November 2011).
  7. Department of Health website. NHS inpatient elective admission events and outpatient referrals and attendances, quarter ending 30 September 2011. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_131240 (accessed 7 December 2011).
  8. NHS Choices website. Carpal tunnel syndrome. www.nhs.uk/conditions/carpal-tunnel-syndrome/Pages/Whatisitfinal.aspx (accessed 7 December).
  9. Foroughi D, Chadwick L. Accident and emergency abusers. Practitioner 1989; 233 (1468): 657–659.
  10. Crombie D. A casualty survey. J R Coll Gen Pract 1959; 2: 346–356.
  11. NHS Employers website. Changes to QOF 2012/13. www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/ChangestoQOF2013.aspx (accessed 8 December 2011). G