UK Experience with the Quality and Outcomes Framework

1. UK Experience with the Quality and Outcomes Framework John Hutton IQ Annual Meeting, Hanover February 2012

2. 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

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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)

9. Clinical Domains

10. 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

11. Additional Domains 2006-9 • Depression • Atrial fibrillation • Chronic kidney disease • Dementia • Obesity • Palliative care • Learning disability • Primary prevention of CVD

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Evaluation of QOF • No experimental study designs • Observational data • Poor baseline data so comparison of trends has been used

19. 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

20. End Note • Was it worth it? • Is it worth continuing? • Do the indicators show high performance in service delivery or in negotiation?

21. Thank you for your attention! InterQuality website: http://www.interqualityproject.eu/