NICE Quality Standards & Performance Measures: QOF & COF

1. NICE Quality Standards & Performance Measures: QOF & COF Tim Stokes Consultant Clinical Adviser General Practitioner, Ashby de la Zouch, Leicestershire tim.stokes@nice.org.uk

2. Overview • Performance measures • Quality Standards • Quality and Outcomes Framework (QOF) • Overview of the NICE Managed QOF • Experience to date (2009-2011) • Commissioning Outcomes Framework (COF) • Overview

3. Performance Measures

4. Performance Measures (1)Institute of Medicine, US, 2002 • Patient perspectives • patient assessment and satisfaction with their access to and interactions with the care delivery system • Patient outcomes • mortality, morbidity, and physical and mental functioning • Clinical quality measures

5. Performance Measures (2)Institute of Medicine, US, 2002 • Clinical quality measures • specific quantitative indicators • to identify whether the care provided conforms to established treatment goals and care processes for specific clinical presentations • consist of a descriptive statement or indicator • Have a list of data elements that are necessary to construct and/or report the measure • Have detailed specifications that direct how the data elements are to be collected • may also include thresholds, audit standards, or other benchmarks of performance

6. A performance measure – QOF

7. Where do NICE Quality Standards fit in?

8. What are NICE Quality Standards? Quality Standard: set of specific, concise statements and measures, developed from evidence-based guidance, that act as markers of high-quality and cost-effective care or services in a specific area. NICE quality standards (17) Registration requirements Proportion of services Standard of services Unsafe Substandard Adequate Good Excellent

9. How will quality standards be used? • NHS White Paper Equity and Excellence: Liberating the NHS • “To achieve our ambition for world-class healthcare outcomes, the service must be focused on outcomes and the quality standards [developed by NICE] that deliver them” • Health and Social Care Bill • Secretary of State and National Commissioning Board have a duty to improve quality of services and in discharging this duty they ‘must have regard’ to NICE quality standards • Commissioning guidance for clinical commissioning groups will include NICE quality standards

11. Where quality standards fit in the measurement pathway

12. QOF: paying GPs to perform … Tim Hunkin Under the Pier Show Southwold , Suffolk, UK

13. The QOF • Incentive scheme (2004) • Open to all primary medical care providers • rewards GP practices for implementing systematic improvements in quality of care for patients • Contains sets of clinical, organisational and patient experience indicators • Practices are assessed against the indicators • score points according to their achievement • Points generate income for the practices (P4P) • £1bn ($1.5bn; €1.1bn) spend each year (15% of primary medical care costs) • £76 ($114; €84) per point (1000 points in total) • 25% of GP practice income (2009-10 data)

14. NICE led QOF process (2009 – date) • Independent body with transparent processes • should be clear to all stakeholders why certain clinical areas have been prioritised for development as QOF indicators • Independent Advisory Committee • Indicators published on NICE menu ahead of negotiations • Considers cost effectiveness as well as clinical effectiveness • Net benefit approach used • Indicators are piloted • QOF as a vehicle for quality improvement • existing indicators will be retired • new indicators introduced when certain criteria are met

15. Who does what? • NICE • Manchester and London based • Primary Care QOF Indicator Advisory Committee • The External Contractor • Primary Care Group in the School of Health and Population Sciences at the University of Birmingham in collaboration with the York Health Economics Consortium - YHEC • The NHS Information Centre • Key partners, including UK devolved administrations

16. What is NICE’s role? • √ Managing the process of developing and reviewing the QOF clinical and health improvement indicators • Ensure consultation with individuals and stakeholder groups • Publish an annual “menu” of new, evidence-based indicators • Make recommendations about existing indicators • X Deciding which indicators are included in the QOF • this will continue to be negotiated by NHS Employers on behalf of the DH and the BMA GP Committee

17. How QOF indicators are developed

18. Characteristics of Performance Measures: judgement or improvement? Raleigh VS, Foot C. Getting the measure of quality opportunities and challenges. London: The King’s Fund, 2010

19. Key points in QOF process 24 Months NICE Managed NICE Quality Standards Review of current QOF areas Prioritisation of evidence-based recommendations by QOF Advisory Committee Indicator development, piloting and consultation Review by QOF Advisory Committee and publication DH, GPC and NHS employers Changes to QOF indicators negotiated using the NICE menu

20. NICE and the QOF: experience to date (2009-11)

21. Overall (2009-2011)

22. Retirement (2009-11)

23. The future of QOF?

24. Moving from activity to outcomes

25. Types of QOF Indicators * epilepsy – seizure free in past 12 months ° e.g., BP target; cholesterol target; HbA1c target +delivery of drug therapy or other interventions that directly improve health outcomes; ≈ where the link between process and improvement in health outcomes is less direct (e.g. use of a diagnostic test, clinical measurement, clinical review, advice)

26. The Commissioning Outcomes Framework (COF)

27. Commissioning Outcomes Framework (COF) • The purpose of the Commissioning Outcomes Framework will be to: • drive local improvements in quality and outcomes for patients • hold Clinical Commissioning Groups (CCGs) to account for their progress in delivering these outcomes • Include some proxy indicators of outcomes that are good predictors of improvement • ‘intermediate’ outcome indicators • processes that are shown to have a strong link to outcomes

28. What is a COF indicator? (1) • NICE Quality Standards • Will form the basis of quality indicators that can be used to measure the quality of specific aspects of clinical care achieved through clinical commissioning groups • The focus of NICE’s work will be measuring health care processes that are linked to health outcomes • COF indicators developed by NICE are intended to be indicators for judgement • Working definition: • An indicator used to assess the quality of the services commissioned locally by CCGs, that translate the NHS Outcomes Framework, and other outcomes or proxies for outcomes into indicators that are meaningful at local level.

29. What is a COF indicator? (2) • COF indicators: • measure quality • NHS CB to hold CCGs to account • CCGs to hold providers to account • “outcomes” bit of COF

30. Key points in COF process 12 Months NICE NHS IC NICE Quality Standard Development of draft COF indicators COF Advisory Committee - Prioritisation of draft COF indicators Indicator field testing COF Advisory Committee - Approval of final COF indicators NHS Commissioning Board Recommends COF indicators

31. Any questions?