Quality and Outcomes
Framework Plus
© Copyright NHS Hammersmith and Fulham 2008-9
© Copyright eHealth Unit, Department of Primary Care and Social Medicine, Imperial College 2008
Published by NHS Hammersmith and Fulham.
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Contents
Introduction to QOF+ ... 1
Context ... 1
Defining and measuring the quality of healthcare ... 1
The quality and outcomes framework (QOF) ... 2
Impact of the quality and outcomes framework ... 2
Future changes to the quality and outcomes framework ... 2
Limitations of the quality and outcomes framework ... 3
The role of healthcare in addressing health inequalities ... 3
Effect of measurement on health inequality ... 4
Why have a local QOF? ... 5
How might a local QOF operate in practice? ... 6
Why have a local QOF for Hammersmith and Fulham? ... 6
The need for clinical engagement ... 6
Aims ... 7
Summary of indicators... 9
Higher thresholds for existing Clinical QOF indicators ... 9
New clinical QOF+ indicators ... 11
New non-clinical QOF+ indicators ... 15
QOF+ report on cardiovascular
disease prevention ... 19
Proposed indicators ... 19
Creation of practice CVD at-risk register ... 21
Background ... 21
Priority and relevance to national policy ... 21
Prevalence of condition ... 22
Associated morbidity and mortality ... 22
Local context ... 22
Review of evidence to support the proposed indicators ... 22
Degree of perceived professional consensus ... 24
Degree of perceived support from patients and carers ... 24
Impact on health inequalities ... 24
Health impact ... 24
Workload and training implications ... 25
QOF+ report on alcohol ... 27
Proposed indicators ... 27
Background ... 27
Priority and relevance to national policy ... 28
Prevalence of condition ... 28
Associated morbidity and mortality ... 28
Local context ... 29
Review of evidence to support the proposed indicators ... 29
Degree of perceived professional consensus ... 30
Degree of perceived support from patients and carers ... 30
Impact on health inequalities ... 30
Health impact ... 30
Workload and training implications ... 31
References ... 31
QOF+ report on smoking ... 33
Proposed indicators ... 33
Background ... 33
Priority and relevance to national policy ... 34
Prevalence of condition ... 34
Associated morbidity and mortality ... 34
Local context ... 35
Review of evidence to support proposed indicators ... 35
Degree of perceived support from professionals ... 35
Degree of perceived support from patients and carers ... 35
Impact on health inequalities ... 35
Health impact ... 36
Workload and training implications ... 36
References ... 37
QOF+ report on
smoking in pregnancy ... 39
Proposed Indicators ... 39
Background ... 39
Priority and relevance to national policy ... 39
Prevalence of condition ... 40
Associated morbidity and mortality ... 40
Local context ... 40
Evidence to support the proposed indicators ... 41
Degree of perceived professional consensus ... 41
Degree of perceived support from patients and carers ... 41
Impact on health inequalities ... 41
Health impact ... 42
Workload and training implications ... 42
QOF+ report on breastfeeding ... 45
Proposed Indicators ... 45
Background ... 45
Priority and relevance to national policy ... 46
Prevalence of condition ... 46
Associated morbidity and mortality ... 46
Local context ... 47
Review of evidence to support the proposed indicator ... 47
Degree of perceived professional consensus ... 49
Degree of perceived support from patients and carers ... 49
Impact on health inequalities ... 49
Health Impact ... 49
Workload and training implications ... 49
References ... 50
QOF+ report on ethnicity... 51
Proposed Indicators ... 51
Background ... 51
Priority and relevance to national policy ... 52
Demography ... 52
Associated Morbidity and Mortality ... 53
Local context ... 53
Review of evidence to support proposed indicators ... 53
Degree of perceived support from professionals ... 54
Degree of perceived support from patients and carers ... 54
Impact on health inequalities ... 54
Health impact ... 54
Workload and training implications ... 55
References ... 55
QOF+ report on records ... 57
Proposed indicators ... 57
Background ... 57
Priority and relevance to national policy ... 58
Prevalence of conditions ... 58
Local context ... 59
Review of evidence to support the proposed indicators ... 60
Degree of perceived professional consensus ... 61
Degree of perceived support from patients and carers ... 61
Impact on health inequalities ... 61
Health impact ... 61
Workload and training implications ... 62
QOF+ report on new
patient screening ... 65
Proposed indicator ... 65
Background ... 65
Priority and relevance to national policy ... 66
Prevalence of condition ... 66
Associated morbidity and mortality ... 66
Local context ... 66
Review of evidence to support the proposed indicators ... 67
Degree of perceived professional consensus ... 67
Degree of perceived support from patients and carers ... 67
Impact on health inequalities ... 67
Health impact ... 67
Workload and training implications ... 68
References ... 68
QOF+ report on
patient information ... 69
Proposed indicators ... 69
Background ... 69
Priority and relevance to national policy ... 71
Local context ... 71
Review of evidence to support the proposed indicators ... 72
Degree of perceived professional consensus ... 72
Degree of perceived support from patients and carers ... 73
Impact on health inequalities ... 73
Health impact ... 73
Workload and training implications ... 74
References ... 75
QOF+ report on
patient experience ... 77
Proposed indicators ... 77
Background ... 78
Priority and relevance to national policy ... 79
Local context ... 79
Review of evidence to support the proposed indicators ... 80
Degree of perceived professional consensus ... 82
Degree of perceived support from patients and carers ... 82
Impact on health inequalities ... 82
Health impact ... 82
Workload and training implications ... 82
QOF+ report on
patient safety ... 85
Proposed indicators ... 85
Background ... 86
Priority and relevance to national policy ... 87
Local context ... 87
Review of evidence to support the proposed indicators ... 88
Degree of perceived professional consensus ... 89
Degree of perceived support from patients and carers ... 89
Impact on health inequalities ... 90
Health impact ... 90
Workload and training implications ... 90
References ... 90
Training and support
requirements for QOF+ ... 91
Introduction ... 91
Training and support requirements for selected existing QOF indicators ... 91
Training and support requirements for new QOF+ indicators ... 92
Appendix 1
– Background to the QOF+ development process... 100
Composition of the QOF+ development group ... 100
Process employed by the QOF+ development group ... 100
Approach to development of the scheme ... 100
Appendix 2
– Methodology for the extension of existing clinical QOF targets... 102
Selection of candidate existing indicators for revised upper thresholds ... 102
Methodology for revised target setting for existing clinical indicators ... 103
Methodology for point allocation for existing clinical indicators ... 106
Minimum attainment thresholds ... 109
Exception reporting ... 110
List turnover ... 115
References ... 115
Appendix 3
– Current levels of attainment and exception reporting for existing clinical indicators116
Purpose of these data ... 116Data sources ... 116
Using the graphs ... 117
Asthma 6 ... 118 BP 5 ... 119 CHD 6 ... 120 CHD 8 ... 121 CHD 10 ... 122 CS 1 ... 123 DM 12 ... 124 DM 17 ... 125 DM 20 ... 126 MH 6 ... 127 Stroke 6 ... 128 Stroke 8 ... 129
Appendix 4
– Methodology for the design and development of the new indicators for QOF+... 130
Methodology for the creation of new indicator areas long list ... 130
Consultation with local stakeholders to select priority areas for the development of QOF+ indicators ... 132
Methodology for the development of new indicators ... 134
Consultation with local practices ... 135
Assessment of new indicators ... 135
Response to feedback on proposed new indicators ... 136
Final consultation with local practices ... 137
Methodology for point allocation for the new QOF+ indicators ... 137
Communication with the PCT’s health informatics team ... 138
Appendix 5
– Methodology for the development of the training and support package... 140
Development of the training and support package ... 140
Results of data analysis of practice achievement for selected existing QOF indicators ... 141
Results of practice training and support needs assessment ... 141
Credits
Project board
Josip Car Project Executive, Academic & Clinical lead
josip.car@hf-pct.nhs.uk
Miles Freeman Project Executive, Management lead
miles.freeman@hf-pct.nhs.uk
Yvonne Odegbami Project Manager
Azeem Majeed Academic and Clinical Advisor
Arti Maini Clinical QOF+ Coordinator
Becky Wellburn Non-clinical QOF+ Coordinator
Christopher Huckvale QOF+ Analytics
Sian Clapton Project Finance Officer
Hakan Akozek Chief Information Officer
Xavier Yibowei Head of Informatics
Project governance
Hakan Akozek Deputy Director of Informatics and Quality
Josip Car PEC Chair & Medical Director
Frances Donelly Project Director for Primary Care Quality
Miles Freeman Director of Primary Care and Commissioning
Christopher Millett Consultant in Public Health
Alison Williams Director of Finance
Dagmar Zeuner Director of Public Health
Contributors
Riyadh Alshamsan (Doctoral researcher in health economics)
Josip Car (PEC Chair & Medical Director, GP and Director of e·Health Unit) Miles Freeman (Interim Director of Primary Care)
Christopher Huckvale (Honorary research associate in e·Health) Elizabeth Koshy (Academic GP & honorary clinical research fellow) Arti Maini (Academic GP & honorary clinical research fellow) Azeem Majeed (Head of Department and Professor of Primary Care) Christopher Millett (Academic Consultant in Public Health)
David Morley (Health informatics team)
Sam Nemonique (GP on clinical leadership training)
Shanker Vijayadeva (GP & honorary clinical research fellow) Jill Waddingham (QOF+ Resource Pack Co-ordinator) Becky Wellburn (Head of Primary Care Commissioning) Xavier Yibowei (Health informatics team)
Dominik Zenner (GP and Specialist Registrar in Public Health) Dagmar Zeuner (Director of Public Health)
Delphi local stakeholder consultation group
Josip Car, Miles Freeman, Sheraz Khan, Paul Skinner, Tony Willis, Dagmar Zeuner
Health informatics team
Acknowledgements
We are indebted to the valuable contribution made by the following individuals and groups.
Dr Ike Anya Consultant in Public Health, NHS Hammersmith and Fulham
Dr Mark Ashworth Kings College London
Professor Richard Baker University of Leicester
Patricia Cadden Senior Substance Misuse Commissioning Manager London Borough of Hammersmith and Fulham Christopher Corfield Chief Pharmacist, NHS Hammersmith and Fulham
Gloria-Anne Cox Hammersmith and Fulham TB Action Group
Dr Tim Doran University of Manchester
Professor Colin Drummond Kings College London
Rachel Haffenden Hammersmith and Fulham TB Action Group
Lynne Jones Designated Nurse for Child Protection Hammersmith and Fulham
Professor Helen Lester University of Manchester
Christine McCrudden Hammersmith and Fulham TB Action Group Professor Martin Roland University of Manchester
Professor Aziz Sheikh University of Edinburgh
Dr Michael Soljak Imperial College, London
Tom Stevenson Head of Communications, NHS Hammersmith and Fulham
Dr Richard Williams Lambeth PCT
The NHS Information Centre
GPRD Group, Medicines and Healthcare Products Regulatory Agency Professional Executive Committee (PEC), NHS Hammersmith and Fulham Planning and Strategy Group, NHS Hammersmith and Fulham
We would like to thank all the general practices of Hammersmith and Fulham who participated in the QOF+ consultation process.
In addition, we would like to acknowledge the work of the QOF Review; a collaboration between the Universities of Birmingham and Manchester, the Society of Academic Primary Care and the Royal College of General Practitioners which is led by co-directors Professors Richard Hobbs (UoB) and Helen Lester (UoM). We based the structure of the QOF+ reports on that used in the reports produced through the QOF Review.
Foreword
QOF Plus has high ambition - to deliver world class healthcare. It focuses on helping people
live healthier and longer lives, and above all aims to dramatically reduce health inequalities.
To achieve this vision of better care for all QOF Plus builds on existing systems for quality in primary care and uses the best international evidence to extend these. We know that improving quality is not easy. Yet we also know that it is possible when priorities and the approach to change are right. With QOF Plus we have focused on what matters and makes a difference for both patients and clinicians. We have built into the implementation the best evidence on support for quality improvement. In particular, we want to ensure that individual practices and clinicians are enabled in transforming their clinical practice to make it of consistently high quality.
This publication is accompanied by a support resource pack, guidance on business and financial rules, EMIS and Vision templates for health monitoring, details of a series of training events, visits and workshops. Most importantly, QOF Plus is supported by a committed clinical, academic and management team which aims to provide a range of multimodal supportive strategies to address, in real time, areas of challenge. This is the most significant investment into quality improvement in primary care since the introduction of QOF.
This innovative scheme, developed jointly with experts in our local Department of Primary Care and Social Medicine at Imperial College, combines a strong evidence-based approach with meaningful engagement and consultation with local practices and stakeholders. QOF Plus has been designed in line with national guidance and addresses a range of important national and local health service priorities. It builds on the analysis of the public health needs of Hammersmith and Fulham, and on what local people have told us they want.
Advice offered by national and international experts in health care quality improvement has played a significant role in helping determine the vision and implementation strategy for QOF Plus, ensuring that we learn from past experience in the field. The key individuals involved in designing and developing QOF Plus believe passionately in – and are fully committed to – the principles embodied by the scheme, namely achieving excellence in healthcare for all people and reducing health inequalities; ensuring the healthcare needs of those most vulnerable are addressed. This team is championing the scheme and will, in partnership with patients and colleagues in primary care, work to make it a success.
I am sincerely grateful to all that have contributed to this important project that brings new dynamism to primary care embodying some of the key principles of Lord Darzi’s Next Stage Review. I believe QOF Plus will make a real difference to the people of Hammersmith and Fulham. I also hope that this work will make a valuable contribution to the current national debate about the future direction of QOF, and serve as a model for other PCTs wishing to initiate similar schemes.
Sarah Whiting
Executive summary
Introduction
Previous work has highlighted several limitations of the national Quality and Outcomes Framework (QOF) including insufficient focus on health outcomes, primary prevention, prioritised local health needs and benefits. QOF may not encourage practices in reaching the more challenging patients, as practices do not receive further incentives once they have received the upper payment threshold. It is anticipated that introduction of a local QOF will help address these limitations.
Aims
This document describes a joint venture by NHS Hammersmith and Fulham and the Department of Primary Care and Social Medicine at Imperial College London to design and develop a local QOF for Hammersmith and Fulham (QOF+) which is in line with current national guidance, developed through the process of effective clinical engagement and which aims to have a greater emphasis on prevention, address local needs, accelerate improvement and reduce inequity.
Methodology
Engagement with local practices and other local provider services, feedback from patients and discussions with national and international experts in health care quality improvement provided insights which informed the development of the scheme.
A number of existing QOF indicators were identified as candidates that might benefit from additional incentivisation through the provision of revised upper targets. Indicator selection was weighted towards those whose attainment confers significant potential health benefits at a population level and where current attainment in Hammersmith and Fulham is below that seen nationally.
Potential sources for new indicator areas were identified and prioritised on the basis of being both local and national priorities. These were subjected to a structured consultation with local stakeholders to select areas for indicator development for the first year of the scheme through a consensus process.
Literature reviews of the evidence base were undertaken for each selected indicator area to inform development of indicators.
Proposed new indicators were assessed using the Organisation for Economic Cooperation and Development (OECD) criteria of importance, scientific soundness and feasibility. Each indicator was also assessed for clarity. This assessment was informed by the views of local practices, a local stakeholder panel (through a structured consultation with the aim of achieving consensus for the clinical and records domains), local provider services and national and international experts in the proposed indicator areas.
Like QOF, QOF+ includes a combination of all-or-northing and payment stage indicators, re-uses the concept of exception reporting and determines remuneration using a system of population and prevalence-weighted point allocation. The PCT Health Informatics Team was consulted to ensure that proposed indicators would work within primary care IT systems.
The development of a training and support package to support QOF+ was informed by consultation with local and national experts, analysis of data on achievement for existing QOF for individual practices, and a training and support needs assessment conducted among all local practices.
Outcomes
Through QOF+, practices will be rewarded with QOF+ points for achievement of higher thresholds for a selected number of existing national QOF indicators including the following:
Asthma 6, BP 5, CHD 6, CHD 8, CHD 10, CS 1, DM 12, DM 17, DM 20, MH 6, Stroke 6, Stroke 8.
Additionally, practices will be rewarded for achievement of new QOF+ indicators which have been developed in clinical and non-clinical domains covering the following areas: Cardiovascular Disease Primary Prevention, Alcohol, Smoking Cessation (including Smoking in Pregnancy) Breastfeeding, Ethnicity, Records, New Entrant Screening (for Tuberculosis), Patient Information, Patient Experience and Patient Safety.
Anonymised medical records of all registered patients will be stored centrally by the PCT through the use of the APOLLO IT system by practices. This will enable analysis of performance, improved practice profiling, equity assessment using patient-level data, and provision of monthly feedback of performance to practices, as part of a wider training and support package which has been developed to support QOF+.
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Introduction to QOF+
Improving the quality of primary care services in
Hammersmith and Fulham
Context
The purpose of this paper is to provide the rationale and describe the process for implementing a major quality improvement initiative for primary care services in Hammersmith and Fulham, called QOF+. The initiative has been developed by NHS Hammersmith and Fulham in partnership with the eHealth unit of the Department of Primary Care & Social Medicine at Imperial College London.
NHS Hammersmith and Fulham has identified quality improvement in primary care as a key local priority. The PCT has earmarked over £2 million annual funding to implement a comprehensive local financial incentive scheme (QOF+) over the next three years (2008/09, 2009/10, 2010/11). The aims of this scheme are to achieve a step-change in quality and address local priorities. Subject to a positive evaluation, this funding is likely to be extended beyond this period.
Defining and measuring the quality of healthcare
There are currently no internationally agreed definitions of healthcare quality. Maxwell (1983) offers six dimensions of quality in healthcare including appropriateness, equity, accessibility, effectiveness, acceptability and efficiency. One of the most widely adopted definitions of quality is provided by the Institute of Medicine: "The degree towhich health services for individuals and populations increasethe likelihood of desired health outcomes and are consistentwith current professional knowledge” (Institute of Medicine, 2001). Performance indicators are designed to measure the extent to which healthservices meet this goal (Majeed, 1995).
There has been an increased interest in measuring the quality of care over the past decade. In parallel, there have been significant developments in databases, both administrative and clinical, which have enabled collection of routine information on quality. These factors have significantly influenced the development and implementation of performance indicators (Majeed et al., 2007). International evidence underlines the importance of high quality primary care in achieving an effective and efficient health care system and in improving population health (Starfield, 2001). Whilst recent investment in quality initiatives in the UK has led to considerable improvements in primary care, the quality of service provision remains variable in many areas (Gray et al., 2007; Hippisley-Cox et al., 2004).
The quality and outcomes framework (QOF)
April 2004 saw the introduction of the Quality and Outcomes Framework (QOF) as part of the New Contract for General Practitioners where pay was linked to performance with the purpose of driving up standards for primary care. The framework includes quality and performance indicators in a number of domains, including clinical, organisational and patient experience, as well as additional areas such as cervical screening (Roland et al., 2004). The quality measures in 2004 were largely drawn from existing national guidelines, and were designed to reflect widely accepted standards of clinical care. The contract was significantly revised in 2006 following a renegotiation, with the addition of nine areas, changes in indicators and increased thresholds for payment.
Impact of the quality and outcomes framework
GPs have achieved high scores in the QOF in each of the first three years of the scheme. In 2006-07 practices in England achieved an average of 954.5 points, (95.5 percent of the 1,000 available). This compares with an average achievement of 96.2 per cent in 2005-06 and 91.3 percent in 2004-05 against the 1,050 points then available (National Audit Office, 2008).
Early data suggests the introduction of the QOF has shown moderate improvements in outcomes for patient care in some long term conditions such as asthma and diabetes, but not for others such as coronary heart disease (Campbell et al., 2007).
Future changes to the quality and outcomes framework
Built into the new GMS contract is the expectation that QOF will evolve over time. The focus in the first few years of QOF has been on process measures as a first step towards achieving good outcomes. Lester (2008) further comments that “In future, perhaps pay for performance schemes should be actively designed with health inequalities in mind.”
As part of the NHS Next Stage Review, the Department of Health announced proposals for further developing the Quality and Outcomes Framework (QOF) including an independent and transparent process for developing and reviewing indicators. The Review outlined plans to discuss with the National Institute for Health and Clinical Excellence (NICE) and with professional and patient groups how this new process should work, and to explore the possibility of allowing PCTs greater flexibility to select indicators (from a national menu) that reflect local health improvement priorities (Darzi, 2008).
The National Audit Office (NAO) report on GP contract modernisation (National Audit Office 2008) recommended that the Department of Health should:
develop a long term strategy to support yearly negotiations on QOF, and
develop QOF based on patients’ needs and in a transparent way,
base the strategy more on outcomes and cost effectiveness, and
agree to allocate a proportion of QOF indicators for local negotiation at Strategic Health Authority (SHA) or PCT level.
The Department of Health is currently consulting on the proposalto ask NICE to oversee a new independent, transparent and objective processfor developing and reviewing QOF clinical and health Improvement indicators for Englandfrom 1 April 2009 (DoH, 2008).
The Department of Health is also consulting on the proposal that Primary Care Trusts (PCTs) should have flexibility to select additional indicators from the NICE menu to reflect local priorities.
The Royal College of General Practitioners is planning to develop and roll out nationally by 2010 an accreditation scheme for GP practices. It is proposed that this scheme will serve as a vehicle to drive organisational quality improvement, and this is likely to have a significant impact on the arrangements for incentivising organisational quality through the Quality and Outcomes Framework (National Primary Care Research and Development Centre, 2008).
Limitations of the quality and outcomes framework
The National Audit Office (2008) and Fleetcroft el al. (2006) have highlighted a number of limitations of the national QOF: incentivised clinical areas in QOF may not reflect local population health needs, indicators are insufficiently focused on health outcomes, and rewards are insufficiently aligned with prioritised health need or health benefit.
Payment thresholds have arguably been set too low, so that standards recommended in national clinical guidelines are not being achieved for most patients (Fleetcroft et al., 2008). There is some evidence that improvements in care associated with QOF have not occurred in all groups, e.g. ethnic minorities, thereby potentially worsening health inequalities (Gray et al., 2007). Quality indicators in QOF have not been sufficiently weighted towards primary prevention (Darzi, 2008). In addition, Short (2007) notes discrepancies between QOF and NICE guidance in certain areas and comments that “there needs to be some clarity and stream-lining of guidance between primary care and major clinical governing bodies.” NICE is currently examining the fit between QOF and the evidence-based NICE guidelines (Leech, 2008).
The role of healthcare in addressing health inequalities
The principle of social justice incorporated into the Physician’s Charter (Medical Professionalism Project: ABIM Foundation 2002) states that “the medical profession must promote justice in the healthcare system” and that physicians should “work actively to eliminate discrimination in healthcare, whether based on race, gender, socio-economic status, ethnicity, religion or any other social category.” One of the professional responsibilities included in the Physician’s Charter involves improving access to care. This requires that physicians must “individually and collectively strive to reduce barriers to equitable health care.”
Effect of measurement on health inequality
Mant (2008) comments that “in everyday clinical practice, variability in usual care matters most at the tail-end of the distribution where poor care can lead to adverse outcomes including avoidable death.” Evidence from epidemiological studies suggest that while effective regular mechanisms for dealing with poor care are essential, a more effective approach is to develop strategies for raising average performance, and therefore shifting the whole distribution (Rose et al., 1990). An example of this is the introduction of cervical smear targets for UK general practices in 1990. The highest targets were achieved rapidly by practices in affluent areas, and this resulted in an initial widening of the health inequality gap. However, practices in more deprived areas caught up over the next few years, thereby reducing inequality (Baker et al., 2003; Middleton et al., 2003). This phenomenonhas been termed the inverse equity hypothesis (Victora et al., 2000). This hypothesis predicts that the benefits of new public health interventions are initially experienced by the wealthier sector of the population and later by the poor, increasing the inequity ratio. However, once the poor have experienced benefits and a ceiling effect is reached in the richer population, the inequity ratio which initially increases, then decreases.
Although the Quality and Outcomes Framework was not designed to tackle health inequalities (Roland, 2004), there is evidence of the inverse equity hypothesis being relevant to QOF. Data is now emerging which suggests that from a longer term perspective, more equitable healthcare is being generated following the introduction of QOF (Lester, 2008). Ashworth et al. (2008) assessed the effects of social deprivation on levels of BP monitoring and control using data from over 97% of practices in England over the first three years of the QOF. They found that:
“Since the reporting of performance indicators forprimary care and the incorporation of pay for performance in 2004, blood pressure monitoring and control have improved substantially. Improvements in achievement have been accompanied by the near disappearance of the achievement gap between least and mostdeprived areas.”
Doran et al. (2008) looked at overall achievement in 48 of the clinical indicators in QOF and found that median achievement score increased across the board, with the gap in median achievement between practices in the most and least deprived areas reducing considerably.
The evidence suggests that “low scoring practices in deprived areas also seemjust as able to improve the quality of their care (as measuredby the Framework) as low scoring practices in more affluentareas” (Lester, 2008). Lester (2008) further comments that:
“Overall, the financial incentivesseem to have reached areas of high need relatively effectivelyfor most targets. An important subsidiary message is theneed to take a long term view when interpreting the effectsof quality measures on health inequalities.” However, there remains concern that QOF may not encourage practices in reaching the more challenging, hard-to-reach patients, as practices do not receive further incentives once they have achieved the 90% upper threshold for payment (National Audit Office, 2008). This means practices can receive maximum points and payment for every clinical indicator before all eligible patients receive indicated care. Fleetcroft et al. (2008) comment that this can result in an ‘incentive ceiling effect’ with associated reductions in health gains, and state that “there may be no rationale for maximum target thresholds to be set below 100% as there are comprehensive reasons for exception reporting any patient who would not theoretically benefit from the indicated care”. Setting and rewarding achievement of higher thresholds for selected existing
QOF indicators may therefore help to address this issue, with the aim of achieving additional health gains in a more challenging group of patients.
Why have a local QOF?
Local Enhanced Services (LES) already provide scope for local development within the GMS contract. The purpose of these is to allow PCTs to tackle local problems not addressed in the national QOF. These may include a greater emphasis on prevention and strategies designed to reduce inequity. It is anticipated that introduction of a local QOF would confer a number of advantages, including more robust performance reporting, mainstreaming quality through templates and coverage of a greater number of areas.
The concept of developing a local QOF has recently received backing from the National Audit Office (2008) and the NHS Next Stage Review (Darzi, 2008).
Development and implementation of a local QOF may also contribute to PCTs fulfilling their functions as World Class Commissioners. The Department of Health describes World Class Commissioners as being “central to a self-improving NHS. They will operate as learning organisations, seeking and sharing knowledge and skills. World class commissioners will also be stimulating provider and clinical innovation through improvements in experienced quality, access and outcomes” (DoH, 2008). As part of this commissioning process, PCTs are required to “invest locally to achieve the greatest health gains and reductions in health inequalities, at best value for current and future service users”.
The World Class Commissioning programme (DoH, 2008) outlines a series of competencies which commissioners will need to reach world class status. These are:
locally lead the NHS
work with community partners
engage with public and patients
collaborate with clinicians
manage knowledge and assess needs
prioritise investment
stimulate the market
promote improvement and innovation
secure procurement skills
manage the local health system
How might a local QOF operate in practice?
There is ongoing debate about how a local QOF could work in practice. The Department of Health has proposed that to help address local health needs more effectively, PCTs should be able to select local indicators from a national menu of indicators, for use in local voluntary incentive schemes (DoH, 2008).
An alternative is for indicators to be developed locally by PCTs. However, there are practical limitations associated with this approach including:
the need for technical expertise in the development of evidence-based indicators and business rules for extraction of clinical data from GP systems;
the IM&T support required to extract data from clinical systems and to link this with payment calculations (DoH, 2008).
Why have a local QOF for Hammersmith and Fulham?
Evaluations of recently introduced LES and local Shared Care schemes (including CVD Primary Prevention, Smoking Cessation and Alcohol) in Hammersmith and Fulham highlighted a number of problems with these schemes, in terms of their complexity and design and the level of uptake by practices. These highlight a need for widespread implementation in a way that is easily understood. There is also a need to reduce health inequalities and recognition that QOF may be a vehicle to achieve this. Although it has been proposed that PCTs should have flexibility to select local indicators from a national menu published by NICE, the infrastructure required to support development of local QOFs through this approach is not anticipated to be in place until 2011/12 at the earliest (DoH, 2008). It was therefore proposed that NHS Hammersmith and Fulham would develop a local QOF scheme to run initially for 3 years from 2008/9-2010/11, with technical expertise in indicator development being provided by the Department of Primary Care and Social Medicine at Imperial College London in conjunction with national and international experts in this field, and IM&T support being provided by the PCT’s Health Informatics Team.
The need for clinical engagement
Effective local clinical engagement is crucial to the success of service improvement initiatives and its integral role has been highlighted in the competencies of World Class Commissioning (DoH, 2008) and by The NHS Alliance (2003) which states that “front-line clinical staff should be effectively involved in redesign, service provision and in ensuring services are used cost-effectively.” The NHS Alliance further highlights that the engagement of front-line professionals at a strategic level would allow PCTs to draw on a bank of untapped knowledge resulting from the wider experiences of primary care. The involvement of local practices in helping shape QOF+ was therefore seen as a central element of the design and development of the scheme.
Aims
This paper describes the design and development of a local QOF for Hammersmith and Fulham which is in line with current national guidance, developed through the process of effective clinical engagement and which aims to have a greater emphasis on prevention, address local needs, accelerate improvement and reduce inequity.
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Summary of indicators
Higher thresholds for existing Clinical QOF indicators
Practices will receive a fixed number of QOF+ points for reaching or exceeding a revised upper threshold for the indicators detailed below. Point awards will be in addition to those allocated under QOF and based on attainment at close of business on March 31 2010.
QOF
QOF+
Indicator
Upper Threshold
Threshold
& (Tolerance) † Points
ASTHMA 6.
The percentage of patients with
asthma who have had an asthma review in the
previous 15mths
70%
95% (3%)
10
BP 5.
The percentage of patients with
hypertension in whom the last blood pressure
(measured in the previous 9 months) is ≤150/90
70%
90% (2%)
29
CHD 6.
The percentage of patients with
coronary heart disease in whom the last blood
pressure reading (measured in the previous 15
months) is ≤150/90
70%
98% (1%)
6
CHD 8.
The percentage of patients with
coronary heart disease whose last measured
total cholesterol (measured in the previous 15
months) is ≤5mmol/l
70%
87% (2%)
7
CHD 10
. The percentage of patients with
coronary heart disease who are currently
treated with a beta blocker (unless a
contraindication or side-effects are recorded)
60%
87% (1%)
14
CS 1
. The percentage of patients aged from 25
to 64 whose notes record that a cervical smear
has been performed in the last five years
80%
88% (7%)
35
DM 12.
The percentage of patients with
diabetes in whom the last blood pressure is
≤145/85
60%
86% (1%)
5
Continued…
QOF
QOF+
Indicator Upper Threshold Threshold& (Tolerance) † Points
DM 17.
The percentage of patients with
diabetes whose last measured total cholesterol
within the previous 15 months is ≤5mmol/l
70%
88% (1%)
9
DM 20.
The percentage of patients with
diabetes in whom the last HBA1c is 7.5 or less in
the previous 15 months
50%
77% (1%)
20
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
50%
97% (1%)
3
STROKE 6.
The percentage of patients with a
history of TIA or stroke in whom the last blood
pressure reading (measured in the previous 15
months) is ≤150/90 in the previous 15 months
70%
96% (1%)
6
STROKE 8.
The percentage of patients with a
history of TIA or stroke in whom the last total
cholesterol (measured in the previous 15
months) is 5 mmol/l or less
60%
85% (1%)
5
Under the current QOF 2009/10 proposal, DM20 will be replaced by DM23, which lowers the target for HbA1c to ≤7.0. We recognise that attaining this more aggressive target will require significant effort involving potentially large numbers of patients. To reward practices as they progress towards the revised goal, we propose to retain DM20 within QOF+ until the end of March 2010. Since DM20 attainment status will no longer be available through QMAS, feedback will instead be provided through the same mechanism of monthly reporting used for the new QOF+ clinical indicators.
† During consultation with practices concern was raised about the possibility, with an ‘all-or-nothing’ payment mechanism, of receiving no remuneration where the revised target was missed through accidental failures involving small numbers of patients. A range of solutions were considered to address this – including the use of payment ranges, similar to those of QOF – but all were felt to distract from a key aim of the revised targets, which is to drive performance towards the best seen at a national level. It was decided to retain the single upper threshold but to introduce a tolerance (bracketed figures in the table above) which lowers the threshold by the specified amount. Attainment lying at or above this lower figure will be remunerated by receiving half the available points. Where the point number is odd, the points will be divided unequally with the balance in favour of the tolerance payment. The existing 3-month exemption for newly registered patients will be respected across these and the newly introduced indicators.
New clinical QOF+ indicators
New indicators are distinguished from existing QOF targets by the plus (+) prefix. Blanket minimum attainment thresholds will no longer be included in year 1 of the QOF+ scheme (
for more information see Appendix 2, Section A2.4). Point awards will be based on attainment at close of business on November 30 2009.
Cardiovascular disease prevention
Chapter 3 (p19)Indicator QOF+
points
Payment stages
+ CVD PREVENT 1
.
The percentage
of patients on the Practice
CVD At-Risk Register whose notes have a Blood Pressure
recorded in the previous 17 months
8
40-90%
+ CVD PREVENT 2
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a record of BMI
measured in the previous 17 months
8
40-90%
+ CVD PREVENT 3
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a baseline record of
total and HDL cholesterol recorded in the previous 17 months
8
40-90%
+ CVD PREVENT 4
.
The percentage of patients on the Practice
CVD At-Risk Register for whom there is a record of a fasting
blood glucose in the previous 17 months
8
40-90%
+ CVD PREVENT 5
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a record of family
history of CHD in first degree relatives (parents, brothers,
sisters, or children of a patient)
8
40-90%
+ CVD PREVENT 6
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a record of family
history of diabetes in first degree relatives (parents, siblings,
or children of a patient)
8
40-90%
+ CVD PREVENT 7
.
The percentage of patients on the Practice
CVD At-Risk Register who have been offered lifestyle advice on
exercise, and appropriate dietary changes within the previous
17 months
10
40-90%
+ CVD PREVENT 8
.
The percentage of patients on the Practice
CVD At-Risk Register who have been offered statin therapy (in
line with 2008 NICE guidance on Lipid Modification) as part of
their primary prevention management strategy
10
40-90%
It is prerequisite that in order to receive payment for + CVD PREVENT 1, practices have achieved the existing QOF RECORDS 11 Indicator (The BP of patients aged 45 and over is recorded in the preceding 5 years for at least 65% of patients.)
Alcohol
Chapter 4 (p27)Indicator QOF+
points
Payment stages
+ ALCOHOL 1. The percentage of patients on one or more
practice registers for CVD At-Risk, Diabetes, Stroke and TIA,
Hypertension and CHD who have had AUDIT-C or FAST
recorded on the practice system within the previous 17
months
15
20-70%
+ ALCOHOL 2.
The proportion of patients who screen positive
using either AUDIT-C or FAST within the previous 17 months
who are subsequently recorded as having a brief intervention
for alcohol misuse
30
40-90%
It is prerequisite that in order to receive payment for + ALCOHOL 2, practices shall have reached the lower threshold for + ALCOHOL 1.
Smoking
Chapter 5 (p33)Indicator QOF+
points
Payment stages
+ SMOKING 1
. The percentage of patients aged 15 years or
older whose notes record smoking status in the past 17
months, or whose most recent recorded smoking status,
recorded over the age of 25, indicates that they had never
smoked
20
40-90%
+ SMOKING 2
.
The percentage of patients aged 15 years or
older who smoke whose notes contain a record that smoking
cessation advice or referral to a local smoking cessation
service has been offered within the previous 17 months
10
40-90%
Smoking in pregnancy
Chapter 6 (p39)Indicator QOF+
points
Payment stages
+ SMOKING IN PREG 1
. The percentage of pregnant women
whose notes record their smoking status at the time of their
first booking appointment in primary care
3
70-90%
+ SMOKING IN PREG 2
. The percentage of pregnant women
who smoke whose notes contain a record that at the time of
their first antenatal booking appointment in primary care they
have been given smoking cessation advice and details of the
local NHS Stop Smoking Services and the NHS pregnancy
smoking helpline (0800 169 9 169)
Breastfeeding
Chapter 7 (p45)Indicator QOF+
points
Payment stages
+ BREASTFEEDING 1.
The percentage of women who are
recorded as being pregnant on or after December 01 2008,
and who at their antenatal booking appointment in primary
care have been given specific information on breastfeeding,
including information on breastfeeding workshops
4
70-90%
+ BREASTFEEDING 2.
The percentage of babies born on or
after December 01 2008 and breast fed at 6-8 weeks whose
record indicates that breastfeeding support contact has been
offered to the babies’ mother at the time of the 6-8 week
check
6
70-90%
+ BREASTFEEDING 3.
At least 80% of babies born on or after
December 01 2008 have a record of feeding method at the
time of the 6-8 week check
3
-
Ethnicity
Chapter 8 (p51) Indicator QOF+ points Payment stages+ ETHNICITY 1
. The percentage of patients on one or more
practice registers for: CVD At-Risk, Hypertension, CHD,
Diabetes, Mental Health and Stroke and TIA whose notes
record their ethnicity and first language
30
60-90%
+ ETHNICITY 2
. The percentage of patients who have newly
registered with the practice on or after December 01 2008
whose notes record their ethnicity and first language
Records
Chapter 9 (p57)Indicator QOF+
points
Payment stages
+ PRESCRIPTION 1
.
The percentage of individual repeat
medications issued which have a diagnosis or symptom in the
electronic medical record relating to that medication
45
40-90%
+ REFERRALS 1
. The percentage of outpatient referrals made
on or after December 01 2008 where both the referred-to
speciality and diagnosis/symptom triggering referral are coded
on the clinical system
50
70-90%
+ CARERS 1
. Carer status is recorded for 100% of individuals
newly registered on or after December 01 2008
6
-
+ OSTEOARTHRITIS 1
. The practice is able to produce a
register of patients who have osteoarthritis
1
-
+ RHEUMATOID ARTHRITIS 1
. The practice is able to produce
a register of patients who have rheumatoid arthritis
1
-
+ ECZEMA 1
. The practice is able to produce a register of
patients who have eczema
1
-
+ PSORIASIS 1
. The practice is able to produce a register of
New non-clinical QOF+ indicators
New indicators are distinguished from existing QOF targets by the plus (+) prefix.
New patient screening
Chapter 10 (p65)Indicator QOF+
points
+ PATIENT REGISTRATION 1
. The practice is trained in and implements the
PCT TB Early Referral Protocol to identify and refer patients who are newly
registered at the Practice and who are new entrants to the UK from
countries with a high TB prevalence
5
Patient information
Chapter 11 (p69)Indicator QOF+
points
+ PATIENT INFORMATION 1
.
The practice uses the PCT practice information
leaflet template for patients which is designed to include information on
the following:
Preventative services such as stop smoking, immunization and
screening
Choice / Choose & Book
PCT’s Patient Advice & Liaison Service and complaints team
Walk-in and urgent care centres
Practice opening times including extended hours
Information for patients in a range of languages informing them of
their right to interpreting services during appointments
3
+ PATIENT INFORMATION 2
.
The practice takes responsibility for regularly
updating practice information on the NHS choices website
7
+ PATIENT INFORMATION 3
.
The practice has up to date patient
information about local training and support for self-management (in the
form of posters and leaflets) and that these are clearly displayed for
patients in waiting areas.
Patient experience
Chapter 12 (p77)Indicator
QOF+
points
+ PATIENT EXPERIENCE 1
.
The practice takes part in a PCT-led local version
of the Picker Institute patient satisfaction survey
3
+ PATIENT EXPERIENCE 2
.
The practice takes part in a PCT-led feedback
session based on the results of the local version of the Picker Institute
patient satisfaction survey and agrees an action plan including explicit and
appropriate targets that can be used in the following 2 years to assess the
extent to which the action plan is implemented
5
+ PATIENT EXPERIENCE 3
. The practice shares with patients the results and
action plan from the local version of the Picker Institute patient satisfaction
survey. This should be through information leaflets and poster(s) in the
practice’s waiting and reception area, and through the Practice’s Patient
Participation Group where this exists
10
+ PATIENT EXPERIENCE 4
.
The practice can show satisfactory objective
evidence of implementing and achieving the action plan agreed with the
PCT following the PCT-led feedback session based on the results of the local
version of the Picker Institute patient satisfaction survey. Deviations from
the action plan must be described and explained
30
+ PATIENT EXPERIENCE 5
.
The practice has a register of patients who need
signing and interpreting support for appointments, including a record of
first language spoken
5
+ PATIENT EXPERIENCE 6
.
The practice offers double length appointments
to patients identified as needing interpreting and signing support and to all
patients on the learning disabilities register
7
+ PATIENT EXPERIENCE 7
.
100% of carers who are newly registered with the
Practice on or after December 01 2008 have a record of being advised by
the Practice that they can ask Social Services for an assessment of their own
needs
5
+ PATIENT EXPERIENCE 8
.
The practice has a system in place for taking the
special needs of carers into account, including when allocating
appointments and issuing prescriptions
5
+ PATIENT EXPERIENCE 9
.
A named carer is recorded for at least 90% of
patients on the learning disability register
5
+ PATIENT EXPERIENCE 10
.
The practice scores better than the national
average on the local Picker survey response to the statement “I waited
more than 2 working days for a GP appointment”
20
+ PATIENT EXPERIENCE 11
.
The practice scores better than the national
average on the local Picker survey response to the question “Have you had
a problem getting through to your GP practice/health centre on the
phone?”
Patient safety
Chapter 13 (p85)Indicator QOF+
points
+ PATIENT SAFETY 1
.
The practice submits significant event analysis (SEA)
summaries to an annual PCT audit
4
+ PATIENT SAFETY 2
.
The practice can show evidence of reporting incidents
or near misses involving harm/potential harm to patients via the national
reporting and learning system (NRLS) using the standard e-reporting form
4
+ PATIENT SAFETY 3
.
The practice has a system for ensuring that all practice
staff have had CRB checks within the last three years
5
+ PATIENT SAFETY 4
.
The practice has a system in place to assist, where
appropriate, with the multi-agency referral process for investigations
relating to the protection of children and vulnerable adults, including
acknowledging any referrals or requests for information within 2 working
days
7
+ PATIENT SAFETY 5
. The practice has a system in place for identifying
vulnerable children, and this includes cases where a parent is known to be a
substance misuser, has a severe mental health problem, or where there is
domestic violence
8
+ PATIENT SAFETY 6
.
The case conference notes of all children who are the
subject of a Child Protection Plan are scanned into the child’s medical
records
5
+ PATIENT SAFETY 7
.
The practice has a system in place for ensuring that
where a child has been the subject of a child protection plan, this is
recorded as a Significant Active problem in the records of the child, the
parents and other members of the household, and that this leads to
effective flagging of records
C3
QOF+ report on cardiovascular
disease prevention
Proposed indicators
Indicator QOF+ points Payment stages+ CVD PREVENT 1
.
The percentage
of patients on the Practice
CVD At-Risk Register whose notes have a Blood Pressure
recorded in the previous 17 months
8
40-90%
+ CVD PREVENT 2
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a record of BMI
measured in the previous 17 months
8
40-90%
+ CVD PREVENT 3
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a baseline record of
total and HDL cholesterol recorded in the previous 17 months
8
40-90%
+ CVD PREVENT 4
.
The percentage of patients on the Practice
CVD At-Risk Register for whom there is a record of a fasting
blood glucose in the previous 17 months
8
40-90%
+ CVD PREVENT 5
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a record of family
history of CHD in first degree relatives (parents, brothers,
sisters, or children of a patient)
8
40-90%
+ CVD PREVENT 6
.
The percentage of patients on the Practice
CVD At-Risk Register whose notes have a record of family
history of diabetes in first degree relatives (parents, siblings,
or children of a patient)
8
40-90%
+ CVD PREVENT 7
.
The percentage of patients on the Practice
CVD At-Risk Register who have been offered lifestyle advice on
exercise, and appropriate dietary changes within the previous
17 months
10
40-90%
+ CVD PREVENT 8
.
The percentage of patients on the Practice
CVD At-Risk Register who have been offered statin therapy (in
line with 2008 NICE guidance on Lipid Modification) as part of
their primary prevention management strategy
10
40-90%
The proposed indicators are in line with the recently published NICE Guidance on Lipid Modification (2008) and derived from NHS Hammersmith and Fulham’s LES on CVD Primary Prevention.
