PCTs, points and their progress
pharmafile | September 15, 2005 | Feature | |Â Â Â
The Quality and Outcomes Framework (QOF) is the cornerstone of the new GMS contract whereby practices achieve payment for achievement against quality criteria. The framework does not include all of the activities a general practice team undertakes but has been devised around those areas where there is evidence of effectiveness.
The total number of points available is 1,050 and these are split across five domains:
- Clinical- 550 points covering 10 disease states (CHD, stroke or TIA, cancer, hypothyroidism, diabetes, hypertension, mental health, asthma, COPD and epilepsy)
- Organisational-184 points covering five areas (records and information, patient communication, education and training, practice and medicine management)
- Patient experience-100 points covering two areas (patient survey and consultation length)
- Additional services – 36 points covering four areas (cervical screening, child health surveillance, maternity services, contraceptive services)
- Holistic care, quality practice and access – 180 points
The 550 points within the clinical domain include 76 individual indicators which are used to measure the practice's performance and these are split into structure, process and outcome indicators. Taking epilepsy as an example this format becomes clearer:
- Structure indicator – The practice can produce a register of people receiving drug treatment for epilepsy.
- Process indicator – The practice can identify the percentage of patients aged 16 and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months.
- Outcome indicator – The practice can identify the percentage of patients aged 16 and over on drug treatment for epilepsy who have been convulsion free for the last 12 months recorded in the last 15 months.
At the beginning of 2004/5 practices and their PCTs agreed targets and aspirations within the domains and they received a third of their aspiration during the year as an aspiration payment. The remainder was paid when the true achievements were calculated in April 2005.
The Quality Management and Analysis System
QMAS is a single, national IT system used to support the QOF payment process and also provide GP practices and PCTs with objective evidence and feedback on the quality of care delivered to patients. Data to support the clinical quality indicators is extracted from the individual GP clinical systems and sent automatically to QMAS once a month. Organisational, access, patient experience and additional service indicators (ie, those requiring yes/no responses) are entered by the practice directly into QMAS via a web browser linked to NHSnet.
Patient identifiers are not extracted from the GP practice clinical system and QMAS, implemented nationally from August 2004, only stores the numerators and denominators for each clinical indicator together with the yes/no responses associated with the non-clinical indicators.
QOF achievements and payments
The total points achieved by GP practices under the GMS QOF during 2004/5 have now been calculated and the payments made by PCTs. The national average achievement is reported to be around 90% which, with 75 available per point in 2004/5, would give the average GP practice with just under 6,000 patients an achievement payment of 70,875.
This is yet another strain on PCTs' unified budgets which had a predicted achievement of 750 points per practice included within their baseline assessment and therefore gives them a 150 point per practice over-achievement to fund at the expense of other services. The payment per point achieved rises to 120 in 2005/6 and therefore a GP practice with a national average patient population that is able to maintain their achievements at 90% during the second year of the current scheme will receive 113,400.
Public access to QOF results
Many PCTs have received requests for information about the performance of general practices under the QOF made within the context of the Freedom of Information Act. The Act gives people a right of access to recorded information held by public authorities (PCTs, GMS practices and PMS practices, etc) with effect from January 2005.
A newly-established NHS organisation, the Health and Social Care Information Centre (HSCIC), has created an information service based on QMAS data called the Quality, Prevalence and Indicator Database (QPID), managed by the Prescribing Support Unit within the HSCIC.
The QPID service (more information on which can be found at the PSU's website: www.psu.nhs.uk) has been created to meet wider information requirements arising from QMAS and to make the information available to a wider user base, enabling all practices and PCTs to refer any requests for QOF information to the HSCIC. It is envisaged that the key users of the analysis and reporting service will be:
- DH branches, including NSFs and public health
- Healthcare Commission, NICE and public health observatories
- Strategic Health Authorities and PCTs
- Academic departments
Despite the availability of this service from the HSCIC some PCTs have decided to publish their general practices' QOF achievements on their websites and via press releases.
Cotswold and Vale Primary Care Trust have publicised the fact that the average achievement by their general practices during 2004/5 was 1,016 points from the total of 1,050 available (a PCT average achievement of 96.7%). The maximum number of points achieved by one of the practices within this PCT was 1049.9!
In addition to PCTs publicising individual GP practices' performance some SHAs have produced comparisons between the PCTs within their area. An example of this is the North East London SHA which published the following data at its board meeting in May 2005.
The SHAs also state how they propose to use the QOF data over and above validating payments to GP practices:
- Measure progress against selected Local Delivery Plan indicators
- Measure likely progress towards reductions in Public Sector Agreement (PSA) inequality and mortality targets
- Measure progress in reducing local inequalities, using comparative analyses both within the sector and across London
The revised QOF
The QOF will be revised for April 2006 and the consultation on amendments was limited to a six week period, with a closing date for submissions suggesting what should be included of 31 May 2005.
The submissions have been collated by the Department of Primary Care at the University of Birmingham who will be liaising with an Expert Panel who will undertake a formal analysis of the evidence.
The Expert Panel asked for comments and evidence within the following areas:
- Existing clinical areas
- New clinical areas not in the current QOF
- Existing and new organisational indicators
- Existing and new additional services
- Patient experience
The principles underlying the review of the QOF were:
- The number of indicators in each clinical area should be kept to a minimum number compatible with accurate assessment of patient care
- Data should never be collected twice
- Data should never be collected purely for audit purposes
- Ideas for additions need to based on best available evidence
- Supported by good professional consensus
- Likely to have a positive impact on the health of patients
- Measurable in a clear, reproducible and precise manner
The review team also made it clear that as well as new indicators and new areas being considered for inclusion other areas and indicators may be removed or have points reallocated based on achievements in the first year of the current QOF.
The QOF review team received 514 submissions to amend the framework. An initial review of the submissions suggests that the majority of them are focused on the clinical areas. A summary of the submissions show they cover the following areas:
- Approximately half of the submissions relate to existing clinical domains including cardiovascular, COPD/asthma, diabetes and mental health
- A fifth of the submissions are for new clinical domains including renal, osteoporosis, obesity, sexual health and learning disabilities
- A fifth relate to existing organisational domains and new organisational domains
- The remainder are for existing additional services, new additional services and for patient experience
Dr Helen Lester, project lead from the University of Birmingham says: "We are very encouraged by the number of submissions we have received and are grateful to everyone who has taken time and effort to contribute to the review. Over the coming months we will review the evidence base of the submissions working closely with patient groups, stakeholders and a process group whose job it is to make sure the ideas can be turned into feasible indicators that can be supported by primary care IT systems."
With current NHS policy streams focusing on public health issues such as obesity management and the management of long-term conditions such as osteoporosis it will be highly likely that these will feature in the revised QOF that will be implemented from April 2006.
At the time of writing there is no information available on the financial incentives that are likely to be linked to the revised QOF. The government has signalled that there will be no more additional investment in the NHS from 2008/9 as the UK will be at, or above average, EU spending on health as a proportion of GDP. It is likely, therefore, that there may be some additional money for the 2006-8 QOF but beyond that no additional funding will be forthcoming.
Implications for the pharma industry
It is very likely that the existing clinical indicators will be tightened within the new QOF (eg, blood pressure levels within the hypertension domain are likely to decrease). This provides opportunities for those companies who have products that can demonstrate superior efficacy within the existing clinical indicators.
Although long-term outcome measures (eg, reduction in MI, strokes, etc) will always be the main clinical measures used by GPs, simple surrogate outcome measures such as a better impact on BP levels will be attractive to some within the context of tighter QOF targets.
The NHS is changing and moving away from focusing on the delivery of healthcare and towards the maintenance of health with the subsequent focus on public health and the management of long-term conditions. It is very likely that these areas will influence the shape of the new QOF to ensure these policy streams are further inculcated into primary care.
Those companies that have products that can demonstrate effectiveness in health maintenance and maintaining the management of patients in primary care will be well placed in the coming years.
