national qof consultation

National QOF Consultation

Developing the Quality and Outcomes Framework: Proposals for a new, independent process

Tuesday 6th January, Birmingham

Welcome & Introduction

Graham Urwin, Chief Executive, Stoke on Trent PCT

Background to the Consultation

Ben Dyson, Director of Primary Care, Department of Health

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High quality care for all is at the heart of the NHS Stage Review Final Report

Quality at the heart of

the NHS

High quality care for

patients and the public

Freedom to focus on quality

High quality care for all

• Raising standards

• Stronger involvement of clinicians in decision making at every level of the NHS

• Fostering a pioneering NHS

• Empowering frontline staff to lead change that improves quality for patients

• Valuing the work of NHS staff

• Help to stay healthy

• Empowering patients

• Most effective treatments for all

• Keeping patients as safe as possible

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The Quality and Outcomes Framework was the first example of its kind in the world, introducing a dramatically more systematic focus on evidence-based care.

30

95

79

58

4341

72

0

25

50

75

100

AUS CAN GER NETH NZ UK US

12724218281353Enhanced preventive care activities

8796847243762Managing patients with chronic disease/complex needs

2052215—5High ratings for patient satisfaction

239243691033Achieving certain clinical care targets

1982472821735Participating in quality improvement activities

UKGER NZ USNETHCANAUSPercent receive financial incentive:

12724218281353Enhanced preventive care activities

8796847243762Managing patients with chronic disease/complex needs

2052215—5High ratings for patient satisfaction

239243691033Achieving certain clinical care targets

1982472821735Participating in quality improvement activities

UKGER NZ USNETHCANAUSPercent receive financial incentive:

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

GPs are ahead of family doctors in comparator countries in uptake of financial incentives for quality, IT use and chronic disease management

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There is also evidence that the QOF is reducing the gap in performance between practices in areas of high and low deprivation

Source: Doran Tet al; Effect of financial incentives on inequalities in the delivery of primary medical care in England: analysis of clinical activity indicators for the QOF, The Lancet 2008; Vol 372

•Average levels of achievement have increased over the three years of the QOF, and variation in achievement has diminished.

•In year 1, lower levels of achievement were associated with increased levels of deprivation and variation in achievement between practices increased with deprivation.

•In years 2 and 3, practices from the more deprived quintiles improved at the fastest rates and variation decreased.

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Recent research has shown that care for some chronic conditions improved more rapidly when QOF was introduced, although subsequent gains have been more difficult

•The rate at which quality was improving increased for asthma and diabetes immediately following the introduction of the scheme

•The rate of improvement continued for coronary heart disease at the same rate as before the scheme

•In subsequent years, the rate of quality improvement appears to have slowed down

•QOF needs to be continually reviewed in order to support optimum health outcomes for patients

Source: Campbell SM et al; National Primary Care Research and Development Centre

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However, there have been criticisms of early QOF that its clinical indicator set didn’t correlate well with possible population health gains

• QOF indicators are not optimally aligned with interventions and activities that will have the maximum impact on population health

• Cookson et al* correlated evidence on the population health gains from cardiac prescribing interventions with the relevant QOF payments

• Plotted points associated with these interventions against likely lives saved p.a. per 100,000, with a relatively poor fit.

Source: Fleetcroft, R. and Cookson,, R. (2005) Do the incentive payments in the new NHS contract for primary care reflect likely Source: Fleetcroft, R. and Cookson,, R. (2005) Do the incentive payments in the new NHS contract for primary care reflect likely population health gains? Journal of Health Care Research and Policypopulation health gains? Journal of Health Care Research and Policy

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11

The incentives in the Quality and Outcomes Framework for evidence based quality care are predominantly focused on diagnosis, management and secondary prevention of long term conditions.

Everyday activity

Some primary prevention activity clearly takes place in GP practices, but there is no systematic framework for ensuring that people who need it have access to it or for measuring quality.

Prevention points

Only 7.5% of the QOF is dedicated to health promotion/illness prevention, covering:• registers for obesity and learning disability• recording blood pressure and smoking status• having a stop smoking strategy.• for 2009/10: CVD primary prevention and sexual health

Mostly disease management

QOF 2009/10

Primary prevention

Disease management

Organisational

Patient Experience

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National Audit Office Report on GP contract modernisationRecommendations to the Department of Health

• Develop a long term strategy to support yearly negotiations on the QOF and develop the QOF based on patient needs and in a transparent way

• Base the strategy more on outcomes and cost effectiveness

• Agree to allocate a proportion of QOF indicators for local negotiation at Strategic Health Authority (SHA) or PCT level

• Consider the case for time-limiting QOF points.

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Aims and objectives of the new process

• all stakeholders have a clear opportunity to contribute to the development of indicators;

• indicators should address topics of importance to patients, professionals and the health of the public and help professionals;

• Indicators should address inequalities in health;

• indicators proposed for inclusion are based on evidence of clinical and cost effectiveness and make the best use of NHS resources;

• there is an objective and transparent system for setting the value of a QOF indicator;

• existing indicators are reviewed regularly;

• potential new indicators are tested through piloting and considered in terms of whether they are workable;

• all processes and methods are inclusive, open, transparent and consistently applied;

• there are appropriate governance structures and clear working arrangements with other relevant parties.

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Why should NICE lead the process?

• NICE is an independent body with statutory responsibility for providing guidance to the NHS based on evidence of clinical effectiveness and cost effectiveness. The aim is for new QOF indicators to be underpinned by NICE evidence-based clinical and public health recommendations relevant to primary care.

• NICE currently has a very high degree of operational independence from the Department of Health and is responsible for developing its methodology and guidance independently.

• NICE already produces guidance aimed at general practice. It has a well established track record in producing evidence-based guidance and consults widely.

• Asking NICE to manage the new process will build on the excellent work of the current QOF expert panel, whilst also ensuring that the assessment of evidence is clearly seen to be independent of the subsequent process for negotiating and approving changes to the QOF.

• NICE’s guidance is based on a rigorous assessment of the best available evidence and involves wide consultation with stakeholders and an independent appeals process.

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Proposed scope and frequency of review

RCGP practiceaccreditation

Disease management and secondary

prevention(excluding flu indicators)

Advice from JCVI

‘flu indicators

Primary prevention and health inequalities

Indicators within scopeIndicators out of scope

Organisational indicators

Patient experience indicators

GP patient survey

Frequency of output for indicators managed by NICE:

•to review all 88 indicators in 3-4 years (20-30 per year)•cost effectiveness evidence for an additional 10 indicators per year

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20112009 20102008

Government response

Recommendations

Oct - Dec

Jan - Mar

Apr - Jun Jul - Sep Oct - Dec

Jan - Mar

Apr - Jun Jul - Sep Oct - Dec

Jan - Mar

Apr - Jun

GOVERNANCE ARRANGEMENTS

DH consultation

NICE takes over process and

appoints panel

INDICATORS FOR 2010/11

DH

NICE

EXTERNAL CONTRACTOR

NHS E / GPC

Prioritisation

Negotiations Changes tocontract

IT changes

INDICATORS FOR 2011/12

NegotiationsChanges to contract

IT changes

Appraisal

PilotingDevelopment

Consult

Prioritisation

High-level Timeline and Process Chart

SFE in force

SFE in force

PRIMARY CARE PANEL

Recommendations

Recommendations

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Local flexibility

Rationale for local indicators

There may be a high prevalence of certain diseases within a PCT that is not representative of the general population - eg HIV in Southwark, London

Solution

Current barriers to uptake

•need for technical expertise in the development of evidence based indicators;•IM&T support required to extract data from clinical systems and to link this with payment calculations. •no national decisions to set aside part of the £1 billion national investment in QOF for local investment.

Menu of QOF indicators______ ____________ ____________ ______

NHS Employers consult GPC

QOF indicators

% for national use

% for local use

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UK collaboration

• Our aim is for a collaborative approach to developing and reviewing indicators across the four UK countries.

• Each of the four countries could remain within a UK framework, with local flexibility according to specific health needs.

• NICE is responsible for evidence based guidelines for England, Wales and Northern Ireland.

• There is already good collaboration between NICE and NHS Quality Improvement Scotland. In the future, NICE could use guidance developed from other sources, including SIGN guidance, subject to the availability of cost effectiveness information.

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Responding to the consultation

[email protected]

Quality Team, Primary Medical Care, Room 2E56, Quarry House, Quarry Hill, Leeds LS2 7UE

http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_089778

Outline Process for Developing Indicators

Dr Gillian Leng, Chief Operating Officer for NHS Evidence and Deputy Chief

Executive, National Institute of Clinical Excellence

Outline of process for developing indicators for the Quality and Outcomes Framework

National Institute for Health and Clinical Excellence (NICE)

NHS

NHS NSR Final Report

PrimaryCommunity Care Strategy

NSR

Workforce Informatics Leadership

Constitution Prevention Payment System

Innovation

Quality

Measure the quality of patient

care

Publish the quality of patient

care performance

Raise the quality of patient care

Delivering against

Quality Metrics

Quality Accounts

Regional Structures

Role of NICE

National Quality Board

Expanded role for NICE

• Response to ‘the Darzi Review’

– More/faster TAs

– Devices and diagnostics

– NICE Fellows

– More Clinical Guidelines/Public Health guidance

– National Quality Standards

– NHS Evidence

– Quality and Outcomes Framework

Core principles for development of NICE products

• Comprehensive evidence base

• Patient and carer involvement

• Independent advisory Committees

• Genuine consultation and contestability

• Regular review

• Open and transparent process

• Expert input

QOF proposed process

Primary care consideration panel (PCP) - twice per year - prioritise clinical areas for indicator

development and potential inclusion in QOF according to agreed prioritisation criteria.

Panel also consider number of indicators, balance of clinical areas and priorities

Stage 2 – PrioritisationManaged by NICE

Collation and prioritisation of evidence based clinical

recs.

NICE website suggestions on potential clinical priorities relevant

to QOF

Collation of NICE evidence based recommendations relevant to primary care

Information on current

indicators/uptake

Stage 1 – Collation of information

Managed by NICE

PCP - for validation Stage 4 – Validation and publication

Managed by NICE, inc consultation

Validation and publication Publish

Guidance Executive

NHS Employers consult with GPC on

QOF changes

DH consult GPC on wording of directions

Publication of changes to QOF SFE

Stage 5 – QOF changes

Six month pilot phase

Stage 3 – Development

Managed through an external contract bar the

consultation

Indicator development and pilot process

Indicator development

Output Templates

Stakeholder Consultation

24

MONTHS

Process for developing indicators

• Stage 1 – Collation of information

– NICE website suggestions on potential clinical

priorities relevant to QOF

– Collation of evidence based recommendations

relevant to primary care

– Information on current indicators uptake

MANAGED BY NICE


• Stage 2 – Prioritisation of areas for indicator development

- Panel consider numbers of indicators, balance of

clinical areas and priorities.

- Decisions made using prioritisation criteria

- Primary Care Consideration Panel will meet twice a year

- Prioritisation of new areas for the development of indicators and process for dealing with

current indicators

MANAGED BY NICE

Primary Care Consideration Panel

• Chaired by an acknowledged expert in primary medical care

• Formal Advisory Body status• Meet twice a year• Approximately 30 individuals• Range of experts and representatives of primary care

workforce– GPs, patients or carers, commissioners, practice

nurses social care professionals from countries taking part and health economists and information specialists


• Stage 3 – Indicator Development (managed through external contract bar consultation step)

- Piloting of indicators

- External stakeholder consultation run by NICE

- Current indicators reviewed and cost effectiveness methodology applied

- New indicators developed

MANAGED EXTERNALLY

Assessing cost effectiveness-General principles

• An indicator is cost effective where net benefit >0Net benefit = (monetised benefit – delivery cost) – QOF payment

• Delivery cost is the cost to deliver the treatment/intervention offset by any savings where new treatments replace older treatments

• Monetised benefit is derived from the expected increase in quality adjusted life year (QALY). NICE will need to identify an appropriate QALY threshold cost, which is expected to be within the range £20,000-£30,000

• QOF payment is an initial incentive to embed within general practice best evidence-based care that will continue to improve patients’ care and health


• Stage 4 – Validation and Publication

- Menu of new indicators and information about current indicators

- Recommendations about review dates- Potential upper and lower thresholds

- Assessment of evidence on cost-effectiveness to inform decisions on the value of indicators

- Validation and publication of outputs via NICE website

MANAGED BY NICE


• Stage 5 – QOF changes

- Publication of changes to QOF Statement of Financial Entitlements

- DH consult with GPC on wording of directions

- NHS Employers consult with General Practice Committee (GPC) on QOF changes

- Indicators published on NICE website fed into DH for negotiation

MANAGED BY DH

Next steps• Tender process for external contractor currently running

– At consultation events, a record of questions is being kept and will be communicated to all interested parties as part of the tender procedure

– Should anyone be considering bidding, any discussion in response to the questions raised at the events will not constitute the office tender view

• Timelines– Offers submitted by 6th February 2009– Interviews to be held between 9-13th March 2009– Contract to be in place by the start of April 2009

Next steps

• Recruiting to Primary Care Consideration Panel early 2009

• Setting up internal project management structures

• Proposed process for indicator development will be subject to consultation in 2009

Panel Q & A Please wait for a microphone before

asking your question Please state your name and

organisation Please keep your questions in the

context of the Consultation

Workshop Briefing

Refreshments

Please be ready to start Workshop

Session One at 12.00

Workshop Sessions

Criteria for selection processRoom: Orchid

QOF cost effectiveness methodologyRoom: Palm Room

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Remit1. Is the proposed topic within NICE’s remit?2. Has NICE already provided guidance or is NICE developing guidance on the

proposed topic?3. Is the topic one where GPs can have a significant contribution to make in terms of

improving patients’ health?

Health improvement and reduction of health inequalities1. Do the proposed indicators relate to an NHS clinical priority areas, or to other

health-related government priorities?2. Do the proposed indicators address an area of action where introduction of

evidence-based indicators in primary medical care would lead to cost effective improvements in the delivery of health care?

3. Are the consequences understood? Are the costs for other sectors proportionate? Are they affordable and deliverable in the short term?

4. For public health topics, do the indicators address an area of public health action that promotes population health?

5. For clinical topics, do the indicators address a condition which is associated with significant morbidity or mortality?

Draft selection criteria for areas for developingindicators for the quality and outcomes framework

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Effect of interventionDo the indicators:1. significantly improve patients’ or carers’ quality of life; and/or2. reduce avoidable morbidity; and/or3. reduce avoidable premature mortality; and/or4. reduce inequalities in health relative to current standard practice if used more

extensively or more appropriately?

Timeliness1. Is this an area of QOF where existing indicators are coming up for review?2. Would new indicators support implementation of new NICE guidance or National

Service Frameworks which are in development or recently published?3. Is there emerging evidence for developing new indicators with direct health

benefit where there are currently no indicators or where existing indicators do not measure direct health benefit?

4. Is there a degree of urgency for introducing indicators caused by factors other than those listed above, for example, significant public concern, a new disease, an important new area for public health action?

5. Would the indicators still be relevant and timely at the expected date of use?

Draft selection criteria for areas for developingindicators for the quality and outcomes framework

Feedback, Other Issues & Next Steps

Graham Urwin, Chief Executive, Stoke on Trent PCT

Event Close

• Thank you for attending

• Please remember to hand in your delegate badge for recycling

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Responding to the consultation

[email protected]

Quality Team, Primary Medical Care, Room 2E56, Quarry House, Quarry Hill, Leeds LS2 7UE

http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_089778

national qof consultation

Documents

qualityhigh quality

nhshigh quality care

director of primary

rate of quality improvement

national primary care

outcomes framework

evidencebased care

criticisms of early