The QOF comes of age

The Quality and Outcomes Framework has proved a demanding taskmaster in general practice, but the signs are that it is becoming more manageable – even though the Autumn brings the usual round of changes to which practice nurses must adapt

After a more than a decade of tumult, the Quality and Outcomes Framework (QOF) appears to have finally entered a phase of decorous tranquillity, which is much to be welcomed, after its initial brattishness and its ‘terrible twos’. At first the whole idea of performance-related pay was thought to be outrageous and unprofessional. The mechanism is that money was taken out of general practice, with the opportunity for practices to re-earn this money if various quality targets were recorded.

At first the QOF targets only bore a superficial relationship to the truth. I still have a copy of the very first QOF documentation¹ which set out the initial targets. There is an occasional reference to available guidelines (curiously SIGN, the Scottish Intercollegiate Guidelines Network, is quoted the most), but no other evidence was supplied, and certainly no evidence at all that the activity required by the QOF had ever been shown to keep patients any healthier. This is perhaps not surprising because applying performance-related pay to an entire country’s healthcare had never been tried before. Caution should perhaps have suggested some pilot studies first. To give you a flavour of the sorts of reasons given for QOF targets at their very beginning, here is a quotation referring to the requirement that smoking status in asthmatics is recorded:

‘The number of studies of smoking related to asthma are surprisingly few in number (sic)....It is recommended that smoking cessation be encouraged as it is good for general health and may decrease asthma severity’.

Evidence was clearly not uppermost in the writer’s mind, and neither was literacy or proofreading.

Yet for all its dubious beginnings, the QOF has mellowed with time. Over recent years NICE (the National Institute for Health and Care Excellence) has become involved and so the evidence for the QOF targets has become much better publicised. Suddenly all this QOF activity does not seem as pointless. The other welcome change is the reason for this article: proposals for changes in the QOF for 2016-17 were published for discussion in August 2015. This can be favourably compared with previous years when either practices were notified of QOF changes after the date that they were supposed to be implemented, or else told that the changes were to be imposed without agreement. Agreement now has to be secured between NICE, the British Medical Association, NHS England and NHS Employers, but there is at least a fighting chance of getting things in place before next April Fools’ Day.

This process has been helped because the QOF has slimmed down – about a third of the points have been lost, or ‘retired’ in the jargon. This means that for practices, getting organised for the QOF is less of a pain in the neck and there are also less QOF targets for politicians to tinker with. Such a removal of red tape is to be welcomed.

THE CHANGES AT A GLANCE

A press release from NICE issued on 3 August (2015) reports Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE as saying: ‘All of the indicators are based on the best evidence and have been developed in consultation with professional groups, patients and community and voluntary organisations. They have also been tested across general practice to make sure they work.’²

There isn’t much detail of how the new indicators have been tested and with what result. This is an important and worrying omission given that the QOF has a history of being cavalier with the evidence. The NICE proposals³ direct the reader to the NICE website for further documentation. To save you the trouble (and it really is a pain trying to navigate the NICE website) I have had a look at two new indicators on your behalf.⁴ Each offers as supporting evidence a pilot scheme. The schemes both carry the names of the University of Birmingham and the University of York, both highly reputable institutions. Each pilot scheme has an identical number of participants and GP practices, so it is to be suspected that they were both done in the same practices. Both the pilot studies only refer to the acceptability of the indicators to the GPs and other practice staff (including practice nurses). There is no mention of patients, and no mention of whether applying the indicator did any patient any good.⁵ This really is quite poor – and evidence buried is as bad as no evidence at all.

New indicators

There are just four of them.

Mental Health NM120. ‘The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses aged 25-84 (excluding those with pre-existing CHD, diabetes, stroke and/or TIA) who have had a CVD risk assessment performed in the preceding 12 months (using an assessment tool agreed with the NHS Commissioning Board)’.

It would be hard to argue with this one. It is known that people with severe mental health problems suffer excessive mortality generally, and in particular coronary heart disease.⁶ Previous QOF indicators included a requirement to check blood pressure and alcohol use: NM120 extends this work.

• See Why we need to do more to tackle cardiometabolic risk in patients with serious mental illness, Practice Nurse January 2015; 45(02):18-22

Obesity NM121. ‘The percentage of patients with coronary heart disease, stroke or TIA, diabetes, hypertension, peripheral arterial disease, heart failure, COPD, asthma and/ or rheumatoid arthritis who have had a BMI recorded in the preceding 12 months’.

In the current year there is a QOF requirement (OB002 in the Public Health domain) to keep a register of all patients over 18 with a BMI of 30 or over. NM121 is therefore just an extension to actively seek out BMI levels in people with a group of conditions known to be associated with obesity. This feels logical, and I can’t imagine it will require much change for most practices. Whether Body Mass Index is the most appropriate measure is more contentious.⁷

Immunisations NM122. ‘The percentage of patients with coronary heart disease, stroke or transient ischemic attack, diabetes and/or chronic obstructive pulmonary disease who have influenza immunisation in the preceding 1 August and 31 March’.

It is curious that this should be termed an addition as there are requirements in this year’s QOF for an influenza immunisation in each of the clinical categories mentioned. Therefore it is hard to know what this allegedly new indicator will achieve. Or, looked at another way, there is no reason to object to the indicator. Patients who have any or indeed several of these conditions are more at risk if they do contract influenza, so that taking steps to prevent this is sensible.

Depression and anxiety NM123. ‘The percentage of patients with a new diagnosis of depression and/or anxiety disorder in the preceding 1 April to 31 March, whose notes record an offer of referral for psychological treatment within 3 months of the date of diagnosis’.

In the current year there is only one indicator for depression, dealing with a requirement for early review. There are no indicators at all for anxiety. NICE guidance on Depression (CG 90) and Anxiety (CG 113) both mention the value of psychological interventions either with or instead of medication. Mental health problems provide so much work in primary care that it would be an odd clinician who was not well aware of the contribution of colleagues in the psychological services. The indicator stipulates that there should be an offer of psychological treatment within 3 months of diagnosis. Of course, if it had said that psychological treatment should have commenced within 3 months, it would have been so wildly optimistic – given the present level of NHS resources – that no practice would get any points.

Changed indicators

There are seven of these.

Obesity NM128. The previously required register of patients diagnosed with obesity is extended to include a BMI of 25 or more. This is in accordance with NICE guidance (CG 189). There is a ‘J’ shaped relationship between BMI and mortality, the lowest mortality being at BMIs of between 20 and 25.8 However, the risks do not really take off until a BMI of 35. According to recent figures, 67% of men and 57% of women in the UK have a BMI of over 25.9 I have looked at the first 12 names alphabetically in the England Rugby squad for the World Cup: every single one of these international-standard athletes has a BMI of over 25, and that includes a scrum half. If you put everyone on the practice register onto the ‘fatties list’ you would not be far wrong. And since when was obesity a responsibility of primary care? What about government food policy? What about exercise accessibility? What about the advertising of chocolate?

CHD primary prevention NM132 and NM133. This refers to patients newly diagnosed with hypertension where at present there is a requirement for a face-to-face consultation to assess CHD risk, and that this assessment should use a validated assessment tool. The changes here are the inclusion of type 2 diabetes, an extension of the age range (from 30 to 74, to 25 to 84), and the recommendation to use the QRISK2 assessment tool which most practices are using anyway.

This represents a tightening of the risk-management net, a trend we have been witnessing for a number of years. Illness is now not just the existence of symptoms and incapacity, it is the possibility of future illness and incapacity. Everyone is a patient and requires healthcare input. There is potentially no end to the meddling that doctors and nurses are allowed to inflict, and the anxiety that this is allowed to generate.

These are the indicators which, when first rumoured, produced a howl of anguish in the medical press. Poor old NICE has strict financial criteria by which it has to judge the advisability of a healthcare intervention. CHD risk is linearly related to cholesterol levels, so that absolutely everyone has something to gain from taking a statin, but for those already at low risk that gain is tiny. Atorvastatin, currently the statin-de-jour, came off patent recently and the price plummeted. So just looking at the financial sums, NICE reduced their recommended threshold for intervention with a statin from 20% to 10%. This means that a quarter of the entire population over 30 should be on a statin.¹⁰ Are all these people ill? Not yet, and probably never will be. Are the purveyors of statins rubbing their hands with glee? You bet they are. All this has come at a time when questions have also been asked about the evidence for the use of statins in CHD prevention, with the suggestion that not all the relevant evidence is available for scrutiny.¹¹ Fortunately sanity and prudence have prevailed, and when the QOF proposals were published, NICE had reverted to a treatment threshold of 20%.

Mental Health NM129 and NM130. This is the requirement to check cholesterol and HbA1c in patients with severe mental illness. The age threshold has been reduced from 40 to 18. These indicators run in parallel with NM120 above, and the reasoning is similar. Curious then that different age thresholds should apply.

Smoking NM124 and NM126. This year SMOK002 requires an annual review of smoking status in vascular disease and severe mental health. NICE has advised a splitting off of the mental health diagnoses into NM124 so that the problems borne by this population can be looked at in one chunk. Again there is no justification offered for this change, other than that NICE recommends it. Smoking status is important to everyone, ill or not. Would it not be simpler to ask everyone who walks through the surgery door about their smoking habits?

There are also likely to be a number of updated indicators for asthma and diabetic foot problems, based on as yet unpublished guidance from NICE. These are expected to be added to the QOF update once the respective guidance is published.

CONCLUSION

The QOF changes every year (except for last year), so that coping with the changes in general practice has become an annual ritual. There is always something to moan about. Change involves work, and all primary care workers are working plenty hard enough already.

The advertised purpose of the QOF is to drive up clinical standards in primary care. Nobody objects to that: neither politicians, taxpayers, patients nor practice nurses. The process has been and continues to be traumatic, and evidence that it has done any good is hard to find. However, the involvement of NICE has brought about a vast improvement in the credibility of the QOF targets. But it also remains work in progress.

Footnote

Incidentally, if any practice nursing colleagues out there are thinking that they are entitled to a share of the annual QOF bonus (the monies that reach the practice when the annual QOF achievement has been finalised), then reflect that this is not new money. I can imagine the reaction of the practice nurses that I work with if they were offered an immediate pay cut, in the hope of an annual bonus based on work they had done up to 15 months previously!

REFERENCES

1. NHS Confederation/BMA. The New GMS Contract. May 2003

2. NICE Press Release 3 August 2015: NICE announces new indicators for improving care in general practice. https://www.nice.org.uk/news/press-and-media/nice-announces-new-indicators-for-improving-care-in-general-practice

3. NICE. New indicators to be added to the NICE menu for the QOF and amendments to existing indicators. 3 August 2015 http://www.nice.org.uk/media/default/Standards-and-indicators/qof-summary-august2015.pdf

4. University of Birmingham and University of York Health Economics Consortium (NCCID). Development feedback report on piloted indicators. Serious mental illness. http://www.nice.org.uk/Media/Default/Standards-and-indicators/QOF%20Indicator%20Key%20documents/nm120-piloting-report.pdf

5. University of Birmingham and University of York Health Economics Consortium (NCCID). Development feedback report on piloted indicators. Obesity http://www.nice.org.uk/Media/Default/Standards-and-indicators/QOF%20Indicator%20Key%20documents/nm121-piloting-report.pdf

6. Brown S, Kim M, Mitchell C et al. 25 year mortality of a community cohort with schizophrenia. British Journal of Psychiatry. 2010. 196: 116-21.

7. NHS Choices. Why body shape matters. http://www.nhs.uk/Livewell/loseweight/Pages/Appleorpear.aspx [Accessed 12.8.15]

8. Berrington de Gonzalez A, Hartge P, Cerhan JR, et al.Body-Mass Index and Mortality among 1.46 Million White Adults N Engl J Med 2010; 363:2211-2219

9. Boseley S. UK among worst in western Europe for level of overweight and obese people. The Guardian 29 May 2014

10. Goldacre B & Smeeth L. Mass treatment with statins. BMJ 2014;349:g4745

11. Goldacre BM. NICE must do better at summarising evidence on statins. BMJ 2014;349:g5081