Root and branch reform of QOF for year ahead

The Quality and Outcomes Framework (QOF) is 10 years old. So how has it fared as it enters its second decade? How does it measure up to the standards set when it was incorporated into the GP contract on 1 April 2004? Is it still fit for purpose? And crucially, what change is required of primary care to manage the QOF for next year?

When the QOF was set up, three principles were outlined about which aspects of primary care should be subject to standard-setting. These were:

• Where responsibility for ongoing management of the patient rests primarily with the GP and the primary care team
• Where there is evidence of health benefits resulting from improved primary care
• Where the disease is a priority in a number of the four nations

Money was diverted from other funding streams in general practice into a new stream based on the achievement of quality standards. At present those standards fall into two categories or 'domains':

• Clinical — this domain has indicators across different clinical areas e.g. coronary heart disease, heart failure and hypertension.
• Public health (PH) — this domain has indicators across clinical and health improvement areas e.g. smoking and obesity.

PH also includes an additional services sub domain, which has indicators across the two service areas of cervical screening and contraceptive services.

At first, general practitioners could not believe their luck. Because it is staffed by professionals, general practice was already performing at such a high level that in most cases QOF money was achieved without doing anything differently, except for recording things better. The money flowed in, and new services developed. Many of the practice nurses employed today owe their jobs to the existence of the QOF money. However, the Government ended up paying practices more than it had planned, so for the last 10 years has consistently tried to claw money back by raising achievement thresholds and by withdrawing QOF points.¹

When QOF points are removed or an entire indicator is retired, this is not because the target to which the indicator applies has become less important or is no longer important. No government wants to tell their electorate that they are no longer bothered by a health quality standard. If most general practices are hitting the target, then government starts to argue that the standard has become part of normal general practice responsibility and so is no longer eligible for extra funding. Furthermore, standards required by the Care Quality Commission (CQC) now include many of the things that the QOF used to support but now does not.

The QOF was not piloted; it was derived from the target mentality of the age when it was implemented. There are no international comparisons as never before had an experiment of this nature been applied to an entire country. There is little evidence that standards of care have been driven up through the QOF as they were rising anyway.²

NEW FOR 2014-15

Readers of Practice Nurse will recall that the QOF deal for 2013-14 was not agreed with general practice, it was imposed by Government. This generated a great deal of resentment, but in most cases general practices accepted the inevitable and just got on with it. By contrast, on 15 November 2013 it was announced that a deal had actually been agreed. A big chunk of QOF points were to be retired and the money saved shifted into the core general practice funding that practices get (money not dependant on outcome measures). Stephen Golledge, lead negotiator for the NHS Employers organisation, hailed the deal: 'In the current economic climate, this is a good deal for patients, GPs and commissioners.' Dr Chaand Nagpaul, Chair of the BMA's General Practitioners Committee, said: 'This agreement has the potential to be good for patients and lessen the severe pressure that many GPs are facing.'³ The aim of the changes is to: 'Free up GP time and reduce box-ticking'. You can judge for yourself whether the changes will meet this aim. (At present the new deal only applies to England)

Compared with 2013-14, 341 QOF points are being 'retired' (which leaves a remainder of 559 points to pursue). Of these retired points, 238 points will be transferred into core GP funding, 100 will be used for new Enhanced Services, and three will be transferred into the Learning Disabilities Enhanced Service. The retired points are given in Table 1.

In addition there have been some changes to some of the old indicators. In many cases this is just a tweak of the time constraints or a change in the name of the Indicator. There is only one significant change as shown in Table 2.

IMPACT

Many practice nurses and GPs will be breathing a long sigh of relief over these latest changes. As long as the practice QOF templates can be altered in time, there will need to be measurably fewer ticks in boxes, and less bickering in the practice when ticks (and points) have been overlooked. So this surely must be good news for general practice, allowing more time to be spent on patient care? However there must be a few caveats.

It has been promised that the money saved by the retirement of points will stay within general practice. If this is true, then it is good news. If the Treasury remains fixated on the need to reduce public expenditure and decides that this money should bear its share of cutbacks then the outlook is less rosy.

Some more of the money saved from the QOF is to be used to support fresh Enhanced Services. The detail of these Services will be the subject of another article. However, we have seen this device before where it is only possible for general practices to recoup money lost by doing extra work. So, same resources, more work.

Since the QOF was linked up with NICE, it is fair to say that the QOF indicators have been much more closely aligned with what is considered to be good medical practice. General practices are committed to providing the best services to their patients anyway, so they will want to maintain high clinical and organisational standards even if the points and financial incentives are removed or 'retired'. The Care Quality Commission (CQC) will still ensure that targets are met, so the only work being saved by practices is the box-ticking, and not the work of maintaining high quality.

PRODUCTIVITY

All the 'Quality and Productivity' indicators are being retired. These indicators are all about how GPs should be stopping their patients going into hospital. This must be considered a curious change as a lot of recent rhetoric in the Press and Parliament has pilloried 'lazy' general practices making inappropriate referrals, or by being so inaccessible that patients are forced to use emergency services. In reality, general practice is working harder than ever (consultation rates are rising inexorably, so some people must be able to get an appointment!)⁴ and the reason why patients access emergency services is more complicated than is sometime envisaged, including as it does demographic and perceptual shifts in the population. So any efforts that general practices make are likely to have a marginal effect at best. In any case nobody really knows what the 'correct' use of hospital referrals or emergency attendances should be: it is easy to calculate an average (and, horror of horrors, 50% of general practices are below average — that's what an average is), but impossible to estimate who out there might benefit from an Accident and Emergency Department attendance but does not go.

The remaining 'Patient Experience' indicator is also being retired, with a considerable loss of QOF points. The target used to be 10 minute appointments for booked doctor surgeries, and 8 minute face-to-face contact for unbooked surgeries. It should not be supposed that this is an effort to improve GP productivity by going back to the old routine of 5 minutes for each patient (or even 3 minutes at a surgery I heard about where the consultation was held over a raised counter so there was no need for the patient to sit down). Multiple patient problems are now the norm, and despite these laudable efforts to reduce bureaucracy, there are still plenty of tasks left. Even if you tried to book a surgery at less than 10 minutes per appointment it would inevitably over-run.

CURIOUS DECISIONS

More than two thirds of all the QOF points available for depression — the ones related to the bio-psycho-social assessment of people with a new diagnosis of depression — are being retired. Labelling someone with a low mood as 'depressed' is often a preliminary to offering medication. An exploration of a patient's circumstances and support is usually a way of avoiding unnecessary antidepressant drugs, and a way of exploring alternative forms of treatment. So it seems a bit of a shame to remove this emphasis and thereby risk the over-use of drug treatment.

Nearly all mention of cholesterol targets has been removed. For established coronary heart disease, peripheral arterial disease and stroke/TIA the indicators have all been retired with a loss of 25 QOF points. Curiously the previous target of 5 mmol/l now only remains in the diabetes indicators. This probably reflects the suggestion in various guidelines that 5 mmol/l is possibly too high.⁵

CONCLUSION

When the QOF was introduced in 2004 it was hoped that clinical standards in general practice would improve. They have improved, but not necessarily because of the QOF. Since then the bar has been raised year by year, partly because governments (on both sides of the political divide) did not appreciate that this was a poor way to manage an institution the size and importance of the NHS, and partly because they were surprised at how good general practice already was. Quite frankly, at its inception some QOF indicators were plain silly and certainly not in accordance with the evidence.

The link with NICE stopped a lot of the silliness, and general practices became proud of their QOF achievement. Just look in the adverts for GP jobs in the British Medical Journal and you will usually see a reference to the QOF points that a practice achieves. And of course, the changes are already made, the nurses recruited, and the templates written to accommodate last year's QOF in the practice.

The changes which come into effect next month must be welcome. Getting GPs and NHS Employers to agree must be a step in the direction of better teamwork. But it is yet another change, and that change has to be managed. I suspect that most practices will heartily embrace the change this time, as long as it is not another excuse for a funding cut.

REFERENCES

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

2. 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

3. NHS Employers and the BMA announce changes to the GP contract for 2014/15 http://www.nhsemployers.org/Aboutus/PressReleases/2013/Pages/gp-contract-for-2014-15-announced.aspx

4. Royal College of General Practitioners. Put patients first. http://www.rcgp.org.uk/campaign-home/~/media/Files/Policy/PPF/Put-patients-first-campaign-brief.ashx

5. Clinical Knowledge Summaries. Stroke and TIA. http://cks.nice.org.uk/stroke-and-tia