UK Experience with the Quality and

Outcomes Framework

John HuttonIQ Annual Meeting, Hanover February 2012

Background

• UK General Practitioners (GPs) are private contractors to the NHS for primary care services

• The General Medical Services Contract is negotiated between the British Medical Association(BMA) and the NHS Employers organisation

• Payment for GPs was based on capitation but since the 1980s elements of pay for performance have been introduced

Pay for Performance in UK Primary Care

• Resisted by the BMA because there might be gainers and losers

• Lack of acceptance that standards of care should be improved

• Small elements of P4P accepted, e.g. for immunisations and cervical smear testing

Changing Attitudes by 2000

• Influence of evidence-based medicine• Acceptance that differing approaches to care

were not justified and deficiencies needed to be rectified

• GPs willing to accept higher performance standards in return for increased payments

• Government willing to put more resources into the NHS

New GMS Contract 2004

• Contract with the Practice not individual GPs• Individual GPs still paid according to patient

list size• Opportunity to increase Practice income

through the P4P scheme based on the Quality and Outcomes Framework (QOF)

Aims of QOF

• To reward good practice• To offer incentives for poorly performing

practices to raise standards• To reduce geographical variation in primary

care provision• To reduce health inequalities• To improve the efficiency of the NHS

Operating Principles

• Measurable indicators of performance• Indicators to be evidence-based• Minimum threshold to earn performance points• Increasing rewards for higher performance• Payments achievable linked to Practice size and

local disease prevalence• Annual renegotiation of indicators, thresholds

and points levels

Design of QOF in 2004

Up to 1050 points awarded in the following areas:• Clinical indicators (550 points)• Organisational indicators (184)• Patient experience (100)• Patient access (50)• Existing fee for service activities (36)• Additional points for overall high achievers (130)

Clinical DomainsCondition No. of Indicators Maximal No. of Points

Coronary heart disease 15 121

Stroke and TIA 10 31

Hypertension 5 105

Diabetes 18 99

Mental Disorder 5 41

COPD 8 45

Asthma 7 72

Epilepsy 4 16

Cancer 2 12

Hypothyroidism 2 8

Total 550

Source: Roland (2004)

Nature of Clinical Indicators

• Taken from clinical guidelines (NICE, SIGN, Royal Colleges)

• Expert panel process to develop indicators• Mixture of process, intermediate and outcome

indicators• Most comprehensive for CVD• Less so for mental health

Additional Domains 2006-9

• Depression• Atrial fibrillation• Chronic kidney disease• Dementia• Obesity• Palliative care• Learning disability• Primary prevention of CVD

Examples of Clinical Indicators

Control of Hypertension:• Blood pressure recorded within last 15

months: lower threshold 25% of patients – 1 point; upper threshold 90% - 7 points

• Most recent blood pressure reading (measured during previous 15 months) was 150/90mm Hg or lower: minimum threshold 25% - 1 point; maximum threshold 70% - 19 points

Exclusion

Patients may be excluded from the numerator and denominator for the following reasons:• Did not respond to 3 invitations for consultation• Newly registered• Newly diagnosed• Declined treatment/intervention• Counter indication, e.g. intolerance or co-morbidity• Already on maximum dose of treatment and failing

to respond

NICE Management of QOF

Key changes from 2009:• Independent Advisory Committee (QOF AC)• Indicators tested for cost-effectiveness as well

as clinical effectiveness• New indicators piloted• Older indicators replaced by new more

demanding ones

Development of New Indicators

• Stakeholder consultation for suggestions• Mapping against NHS Evidence and DH priorities• QOF AC selects for piloting• Piloting to test feasibility, reliability and

acceptability• Cost-effectiveness analysis• QOF AC recommends for adoption• Negotiators consider for inclusion

Retirement of Indicators

Existing indicators must be retired to free points for allocation to new indicators. Criteria for retirement include:• Stable high achievement and low exception

reporting• Process indicator superseded by an outcome

indicator• Poor cost-effectiveness

Evolution of Indicators 2009-11

• Of 153 suggestions 46 (29%) have progressed for development by the QOF AC

• Main reasons for rejection were lack of technical feasibility (49) and insufficient evidence (33)

• Of the 46 piloted, 29 were recommended to the negotiators for adoption and 22 have been included in the QOF

• Of 22 recommended to the negotiators for retirement 10 have been retired from the QOF

Evaluation of QOF

• No experimental study designs• Observational data• Poor baseline data so comparison of trends

has been used

Impact of QOF• Maximum achievement in 2004 could add 25% to Practice

income• Achievement levels high in first year - 83%• Continued improvement in achievement but at same rate

as before 2004• Smaller practices may have reduced variation in

performance• Mixed evidence within disease areas but positive for

diabetes• Quality of services outside QOF may have risen at a lower

rate

End Note

• Was it worth it?• Is it worth continuing?• Do the indicators show high performance in

service delivery or in negotiation?

Thank you for your attention!

InterQuality website: http://www.interqualityproject.eu/