Jumping through hoops:  A survival guide to the Quality and Outcomes Framework

This year's Quality and Outcomes Framework has been the most controversial since QOF was first introduced 9 years ago. Dr Ed Warren offers a somewhat cynical guide to what the changes mean and what is required for 2013-14

The annual round of changes to the Quality and Outcomes Framework (QOF) has this year generated more controversy than usual. Ongoing negotiations between NHS employers and the British Medical Association broke down without agreement, and the Government's proposals were implemented anyway. There was much spluttering within the medical professions. Then followed weeks of frantic activity while practices tried to digest the changes and what they would mean, and the Government was forced into several U-turns. For anyone who works in NHS primary care, it looked like a recipe for a lot of new and effectively unpaid work, putting a further strain on the morale of workers, putting the financial viability of practices at risk, and to some observers, likely to result in deterioration rather than the intended improvement in patient services.

The QOF was set up in 2004. The initial intentions were to provide extra resources for primary care, to improve clinical and other standards, and to introduce a system of performance-related pay. The first intention was achieved very well because general practices were performing better with relation to the standards set than was envisaged: we were doing better than anyone realised, so that extra monies came in and practices employed the nurses and staff needed to maintain the services. Each successive round of QOF changes has sought to claw back these monies.¹ You will have heard your GPs moaning about falling practice incomes, and indeed very few practices are as well resourced now as they were in 2005. So far the pay of practice staff has generally been preserved and it is the practice partners who have taken the financial hit. It is not clear how long this can be sustained — nearly 80% of GPs think that the current round of financial constraints will result in reduced patient services, reduced staffing levels, or both.²

As to the second intention, have clinical standards improved as a result of the QOF? It is not possible to say.¹ Standards were gradually improving before the introduction of the QOF. There was a small surge in recorded performance for the clinical conditions that the QOF incentivised at introduction, but it is not known if this was genuinely improved performance or just better recording. The recording for incentivised and non-incentivised conditions has continued to improve at about the same rate. A recent trans-Atlantic study (the rest of the health world is watching closely how this national experiment works out) showed that more blood pressures were being recorded in the UK (with no obvious surge after 2004) but that hypertension control had if anything deteriorated slightly.³ The QOF was introduced right across primary care, so there is no 'control group' for comparison. Nowhere else in the world has incentivised pay in primary care been introduced to this degree, so international comparisons are not possible either. The jury is still out on the pretty basic question: does the QOF do what it is supposed to do?

What of the third intention, the implementation of performance-related pay in primary care? Many enterprises have tried performance-related pay schemes and a body of evidence is accumulating. It appears to work for people doing simple tasks, but has the opposite effect on people who undertake complex cognitive work.¹ The QOF looks at surrogate markers of care — is the blood pressure under control; are the right checks being done? How this translates into a reduction in strokes or death rates ('hard' end points) is harder to quantify. And it is almost impossible to promise an individual patient that he or she is less likely to be ill or die: the most perfectly treated hypertensive may have a stroke tomorrow and the worst treated may never be affected by his condition. However these are the hard data which patients and governments want.

SHIFTING THE GOALPOSTS

You get QOF points by achieving targets. This is an odd way to go about things if the intention is to improve the treatment of as many people as possible — if you wanted to do that you would make a payment for each patient who gets the service. Having targets actively encourages gamesmanship: for example if the practice is falling far short of the target there is little point in pursuing the target at all, or the difference between payment and non-payment may be a single patient. Once a target has been set it is easy for the Government to take the approach to improvement that requires the least thought, and just increase the target — and that is exactly what has happened this year. For 20 clinical indicators the thresholds for payment have been increased. For CHD006 (patients on aspirin, ACE inhibitor, beta blocker and statin after a heart attack) and HF004 (patients with heart failure who are taking an ACE inhibitor) it is only possible to get maximum points if every single patient is included (upper thresholds 100%). Not a single threshold has been reduced.

Practices with any sense will be actively seeking out patients who can be excluded — excepted — from the targets so that the base number for target assessment is minimised. The box shows reasons why patients can be excepted from clinical indicators.

THE TREADMILL

Until this round of QOF it has been recognised that in primary care the work has to be managed to get it all done — it is not possible to do everything on the same day, or to be in two places at once. Flexibility is needed if the job is to be done properly. The QOF originally recognised this, and accordingly if a clinical check was recommended annually then the practice was given a maximum of 15 months (i.e. 3 months grace) to get it done. This has changed and now 12 months is the maximum gap. In one fell swoop this increases workload with chronic disease management patients by 20%, and ensures that many patients will be seen at an interval of much less than 12 months. No evidence is offered that this will improve patient care,⁴ because it almost certainly won't.

'RETIRED' INDICATORS

Every year some indicators are 'retired' from the QOF, and this year, 165 QOF points have been 'retired', from 20 different Indicators. Some of the indicators have been replaced by other, more stringent, alternatives. Others, such as DEP1 (case finding for depression in chronic disease) have just been dropped. Does this mean that checking for depression is now deemed irrelevant? Not necessarily, it just means that the resources to do the work have been removed. Now the Care Quality Commission (CQC) has reached general practices, the Government has made it clear that it is expected that the 'retired' clinical indicators will still be complied with in order to secure CQC approval of a practice.⁵ (Please note at this point that reference 5 refers to a letter written to the BMA by the Department of Health about QOF changes and dated 18 March 2013, a full 14 days before the changes were due to be implemented). If you know any older dentists, have a chat about the effects of CQC on dental practice. Inspections have caused a lot of dentists to resign. So, far from improving dental practice, CQC resulted in a lot of experienced dentists giving up and taking their experience with them.

NEW INDICATORS

Now to the part you have surely been waiting for — what is new for the QOF this year? In general these days it is practice nurses who run the chronic disease management (CDM) clinics, who work with the computer templates, who write the changed clinical protocols, and who are entrusted with achieving the QOF targets. There have been a lot of changes, so this is a personal choice of edited highlights.

A Public Health Domain has been set up. It is, in the main, a re-arrangement of indicators from different parts of the QOF, so should not present too many problems. It is not too clear why this has been done, except to say that now Public Health has been taken over by local authorities there may be a longer term agenda for this part of the QOF to be devolved. For new and existing Indicators, mention of 'the practice' has been expunged and replaced by 'the contractor'. One can only speculate about the implications of such a change in wording.

DIABETES

DM013. All people with diabetes are to be offered a dietary assessment by a 'suitably qualified professional' every 12 months. 3 points.

Practice nurses at their clinics already offer regular dietary advice to people with diabetes, but the 'suitably qualified' phrase is the killer here. The guidance refers to the Diabetes UK framework,⁶ and cites a reference. I have looked at this, and shown it to my senior practice nurse who has specific diabetes training. None of our team is able to perform at this level without a lot of further training, so for us it can only be implemented by referral to our dietician colleagues: what they think of this is not yet known.

DM014. Newly diagnosed people with diabetes are to be referred to a 'structured education programme' within 9 months of diagnosis. 11 points.

The programme should be group-based and has to fulfil five key criteria. Details can be found in reference 4. Some practices may be able to do this in-house, but the likelihood is that the result will be more referrals.

DM015. All male patients with diabetes are to be asked about erectile dysfunction every 12 months. 4 points.

Many nurses will find this a new area of delicacy, and will wonder if the traditional therapeutic relationship will be jeopardised. Keep in mind that there are no age limits for this indicator.

DM016. All male patients with diabetes with erectile dysfunction are to be offered assessment/treatment for this every 12 months. 6 points.

This makes sense if DM015 is to be implemented. The only treatment options mentioned specifically are phosphodiesterase type 5 inhibitors (sildenafil [Viagra] and similar drugs), and having diabetes means that prescriptions are free, but no doubt if treatment fails further referrals will be needed.

HYPERTENSION

HYP004. Sufferers between the ages of 16 and 74 are to have their physical activity levels assessed ever 12 months using GPPAQ. 3 points.

GPPAQ, the General Practice Physical Activity Questionnaire, is a one sheet form that patients fill in for themselves.⁷ Although this is a validated tool, self-reporting of exercise tends to be unreliable, and the user guidance says that although the questions about walking, housework and gardening have been included, they do not yield any useful data, and do not contribute to the overall activity score.⁸

HYP005. Patients with hypertension who score 'less than active' on their GPPAQ are to be offered a 'brief intervention' to improve their activity levels. 3 points.

The 'brief intervention' recommended includes setting goals, providing information, and follow-up over 3 to 6 months.

HEART FAILURE

A new indicator was considered, requiring an annual offer of referral to an exercise-based rehabilitation programme. This appears to have been dropped from the final guidance⁴ — perhaps because the available programmes would be inundated.

DEPRESSION

The PHQ-9 has been replaced by DEP001, the 'bio-psychosocial assessment' to be done at the time of diagnosis. 21 points.

This should cover 16 areas of enquiry. DEP002 requires a review after diagnosis of not less than 10 days and not more than 35 days (10 points). Most GPs would assess a new patient with depression after 2 weeks, but if there is a suggestion of suicidal ideation then 10 days is far too long to wait.

RHEUMATOID ARTHRITIS

This is the new kid on the block, and generates four new clinical indicators. The pattern is the same as for other conditions.

RA001, there should be a register of cases. 1 point.
RA002, there should be an annual face-to-face review. 5 points.

Most practices are reviewing their patients annually anyway, because of the need for a medication review, so this should not be a problem.

RA003, an annual assessment age 30 to 50 of cardiovascular risk. 7 points.

Patients with rheumatoid arthritis are known to be at extra risk, and risk checking has been recognised good practice for some time.

RA004, two yearly assessment of fracture risk ages 50 to 90. 5 points.

Rheumatoid arthritis is a risk for fractures, and so are many of the treatments, so again this is rational.

CONCLUSION

The QOF is optional. This is slightly bizarre for a government allegedly committed to improve clinical standards. Many practices will be looking at this year's changes and doing the sums — will taking on this new work mean that the practice is not economically viable? Government are relying on primary care teams to keep the show on the road, despite the inexorable erosion of resources and the need to work ever harder, in the sure knowledge that healthcare professionalism will not allow us to take the sorts of actions that would happen in other industries if faced with such behaviour.

It is a balancing act required by any government that is committed to reducing spending, reducing the size of the state, while at the same time trying to prove that they are looking after their electors.

REFERENCES

1.Gillam S and Steel N. QOF points: valuable to whom? BMJ 2013;346:21-23.

2. British Medical Association. Risk Profiling and Care Management Enhanced Service. March 2013

http://bma.org.uk/practical-support-at-work/contracts/gp-contract-survival-guide/survival-guide-des-risk-profiling

3. Serumaga 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

4. NHS Employers. 2013/14 general medical services (GMS) contract quality and outcomes framework (QOF) http://www.nhsemployers.org/Aboutus/Publications/Documents/qof-2013-14.pdf

5. Letter from Richard Armstrong, Head of Primary Medical Care, Commissioning Development Directorate, to the British Medical Association, dated 18 March 2013 confirming a draft of the QOF changes for 2013/14 dated 6 December 2012.

http://www.somersetlmc.co.uk/documents/gms/letter-gp-contract.pdf

6. Diabetes UK. An Integrated Career and Competency Framework for Dieticians

and Frontline Staff. 2011

7. The General Practice Physical Activity Questionnaire. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192450/GPPAQ_-_pdf_version.pdf

8. NHS. The General Practice Physical Activity Questionnaire. http://www.nice.org.uk/nicemedia/live/11927/40195/40195.pdf