Quality and Outcomes Framework

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The Quality and Outcomes Framework (QOF) is a system for the performance management and payment of general practitioners (GPs) in the National Health Service (NHS) in England, Wales, Scotland and Northern Ireland. It was introduced as part of a new general medical services (GMS) contract in April 2004, replacing various other fee arrangements.

Contents

Aims and mechanisms

The QOF was part of a revised contract for GPs. It was intended to improve the quality of general practice and was part of an effort to solve a shortage of GPs. The QOF rewards GPs for implementing "good practice" in their surgeries. Participation in the QOF is voluntary for each partnership, but for most GPs, under the present contract, the QOF is almost the only area where they can make a difference to their income. Almost all participated. Most practices got, and still get, a significant proportion of their income through the QOF.

In the 2004 contract the practice could accumulate up to 1050 'QOF points', depending on level of achievement for each of the 146 indicators. The criteria are grouped into 4 domains: clinical, organisational, patient experience and additional services. The criteria are designed around best practice and have a number of points allocated for achievement. At the end of the financial year the total number of points achieved by a surgery is collated by the QMAS or other system which then converts the points total into a payment amount for the surgery. The formula includes the number of patients and in particular the numbers diagnosed with certain common chronic illnesses; the clinical element awards points for achieving specified clinical "indicators".

A typical clinical indicator would be the proportion of patients with coronary heart disease who had cholesterol measured in the financial year, or the number of patients with depression who have answered a standard questionnaire on severity. Organisational indicators include such things as the availability of practice leaflets and practice staff education.

In the organisational domain the value of points was proportional to the number of patients registered with the practice. In the clinical domain the value of points was further modified by the prevalence of that condition in the practice – this was measured as the square root of the ratio of the national prevalence. For a typical practice the payment was £77.50 per point in 2004/5 and £124.60 in subsequent years.

The QOF system is supervised and audited by NHS primary care trusts in England and the analogous bodies elsewhere in the UK (Health Boards in Scotland, Regional Boards in Northern Ireland and Local Health Boards in Wales), which make the related payments.

Changes to the framework

The GMS contract was revised in April 2006 and, in particular, the QOF was adjusted. The clinical domain was extended from 11 to 18 areas and 138 points were reassigned. The total number of points was reduced to 1000 and the 50 points that were previously attainable through "access points" are now folded into an "access" Directed Enhanced Service (DES). [1] The clinical areas now include coronary heart disease, heart failure, stroke and transient ischaemic attacks, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, epilepsy, hypothyroidism, cancer, palliative care, mental health and asthma. Added in 2006 were dementia, depression, chronic kidney disease, atrial fibrillation, obesity, learning disabilities and smoking.

QOF version 10 was introduced in July/August 2007, with mainly minor changes to the system, removing, adding or changing codes in the clinical areas to bring them in line with current guidance or to fix typing errors.

Further changes to the QOF for 2008 included the addition of new indicators for COPD and smoking cessation. Points have been removed from the access and patient experience domains. [2]

Further changes have occurred on an annual basis although no changes took place for the 2010-11 year for all practices to deal with Swine Flu.

New indicators are developed and approved by a committee of the National Institute for Health and Clinical Excellence. Approved indicators are presented as a "menu" which is passed to the contract negotiators. In the past year only a minority of the indicators in the menu have actually been put into the framework.

QMAS was replaced by the Calculating Quality Reporting Service (CQRS) in 2013. [3]

Exception reporting

The level of achievement recorded depends on the GP treating the patients with the relevant problem(s). But not all patients are treatable or willing to be treated. In order for the GPs not to lose points on account of circumstances that are outside their control they can exclude those patients from counting towards their achievement by "exception reporting" them. Exception reporting is allowed for:

Practices in Scotland have been found to use exception reporting appropriately in that patients who were older or who had dementia were more likely to have been "exception reported". However, younger or more socio-economically deprived patients were more likely to be recorded as having refused to attend for review or not replying to letters asking for attendance at primary care clinics. It has therefore been highlighted that primary care practices should identify and monitor these individuals (i.e. the youngest and most deprived with cardiovascular disease) so that all patients fully benefit from the implementation of the new GMS contract and receive appropriate clinical care to prevent further disability and mortality. [4]

Advantages and disadvantages

Assessments of its success are mixed. The new GP contract as a whole cost £1.76 billion more than the Government had expected, [5] mainly because GPs had been expected to achieve 75% of the available points in the first year and actually achieved 90%.

Tim Burr, head of the National Audit Office, said in 2008: "There is no doubt that a new contract was needed and there are now 4,000 more GPs than five years ago. But in return for higher pay, we have yet to see real increases in productivity." [6]

However, substantial improvements have been noted, particularly in the maintenance of disease registries and screening of risk factors for older patients with cardiovascular disease in the community. [7] [8] [9]

Ben Bradshaw, the Health Minister said: "The GP contract… has stemmed the haemorrhaging of GPs from the NHS and improved the quality of care for the public. Longer consultations, quicker appointments and being able to book ahead are improvements valued by patients."

Laurence Buckman, chairman of the BMA's GP committee, said "The early evidence is that the contract is leading to improvements in clinical care". [10]

A 2016 study published in the Lancet assessed the effect of QOF on mortality. It found that the QOF had no effect on mortality. [11]

Data collection

NHS Digital collects and publishes an annual report using QOF data. As this information is linked to funding GP Practices take a good deal of trouble over it and it enables direct comparisons between practices across England. Data about disease registers and achievement indicators have been collected at the end of March annually since 2004. There are no patient based links, as information about each indicator is collected separately, but it is possible to combine information from different practices to generate area data. [12]

Local alternatives

In June 2014, NHS England approved a local alternative to the framework for practices in Somerset. Under the Somerset Practice Quality Scheme agreement practices that choose to take part only have to formally report against five of the indicators in the 2014–15 QOF. Clinical commissioning groups in Thanet and in York also asked permission to develop a local alternative but were refused. [13]

In January 2017, the clinical commissioning groups in Leeds agreed to suspend 80% of the QOF targets for the rest of 2016/17. A similar strategy has already been adopted by NHS Wales. [14]

Related Research Articles

In the medical profession, a general practitioner (GP) or family physician is a doctor who is a consultant in general practice. GPs have distinct expertise and experience in providing whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide. GPs work at the heart of their communities, striving to provide comprehensive and equitable care for everyone, taking into account their health care needs, stage of life and background. GPs work in, connect with and lead multidisciplinary teams that care for people and their families, respecting the context in which they live, aiming to ensure all of their physical and mental health needs are met. They are trained to treat patients to levels of complexity that vary between countries. The term "primary care physician" is more usually used in the US.

General practice is the name given in various nations, such as the United Kingdom, India, Australia, New Zealand and South Africa to the services provided by general practitioners. In some nations, such as the US, similar services may be described as family medicine or primary care. The term Primary Care in the UK may also include services provided by community pharmacy, optometrist, dental surgery and community hearing care providers. The balance of care between primary care and secondary care - which usually refers to hospital based services - varies from place to place, and with time. In many countries there are initiatives to move services out of hospitals into the community, in the expectation that this will save money and be more convenient.

<span class="mw-page-title-main">Family medicine</span> Medical specialty

Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary care physician, is named a family physician. It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country. The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, focusing on disease prevention and health promotion. According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community". The issues of values underlying this practice are usually known as primary care ethics.

In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.

General medical services (GMS) is the range of healthcare that is provided by general practitioners as part of the National Health Service in the United Kingdom. The NHS specifies what GPs, as independent contractors, are expected to do and provides funding for this work through arrangements known as the General Medical Services Contract. Today, the GMS contract is a UK-wide arrangement with minor differences negotiated by each of the four UK health departments. In 2013 60% of practices had a GMS contract as their principal contract. The contract has sub-sections and not all are compulsory. The other forms of contract are the Personal Medical Services or Alternative Provider Medical Services contracts. They are designed to encourage practices to offer services over and above the standard contract. Alternative Provider Medical Services contracts, unlike the other contracts, can be awarded to anyone, not just GPs, don't specify standard essential services, and are time limited. A new contract is issued each year.

<span class="mw-page-title-main">NHS Scotland</span> Publicly-funded healthcare system in Scotland

NHS Scotland, sometimes styled NHSScotland, is the publicly–funded healthcare system in Scotland and one of the four systems that make up the National Health Service in the United Kingdom. It operates 14 territorial NHS boards across Scotland, supported by seven special non-geographic health boards, and Public Health Scotland.

GPASS, General Practice Administration System for Scotland, is a clinical record and practice administration software package that was previously in widespread by Scottish general medical practitioners. It launched in 1984 and became dominant in the market while still being in public ownership, but a loss of confidence in it led to other systems being adopted and it had been largely been replaced by 2012.

Healthcare in England is mainly provided by the National Health Service (NHS), a public body that provides healthcare to all permanent residents in England, that is free at the point of use. The body is one of four forming the UK National Health Service as health is a devolved matter; there are differences with the provisions for healthcare elsewhere in the United Kingdom, and in England it is overseen by NHS England. Though the public system dominates healthcare provision in England, private health care and a wide variety of alternative and complementary treatments are available for those willing and able to pay.

Practice management is the term used in General practice for the person who manages the finance and administration of a doctor's office or an office of a medical professional in one of many types of specialties in medicine. This is distinct from other official titles such as Advanced Practice Manager, which are generally clinical. A practice manager is responsible for the administrative responsibilities of daily operations and development of a business strategy. Most practice managers are responsible for hiring staff, negotiating benefits and personnel policies, ensuring that medical supplies are ordered and equipment is maintained, ensuring regulatory compliance, and the development and marketing of service lines. Practice management encompasses multiple topics including governance, the financial aspects of medical billing, staff management, ancillary service development, information technology, transcription utilization, and marketing. Practice managers handle the business aspects of medicine to maximize provider time and enhance patient care.

<span class="mw-page-title-main">Clinical commissioning group</span> Healthcare organisation in the United Kingdom

Clinical commissioning groups (CCGs) were National Health Service (NHS) organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in each of their local areas in England. On 1 July 2022 they were abolished, and replaced by Integrated care systems as a result of the Health and Care Act 2022.

Northumbria Healthcare NHS Foundation Trust is an NHS foundation trust which provides hospital and community health services in North Tyneside and hospital, community health and adult social care services in Northumberland.

Michael Alexander Leary Pringle CBE is a British physician and academic. He is the emeritus professor of general practice (GP) at the University of Nottingham, a past president of the Royal College of General Practitioners (RCGP), best known for his primary care research on clinical audit, significant event audit, revalidation, quality improvement programmes and his contributions to health informatics services and health politics. He is a writer of medicine and fiction, with a number of publications including articles, books, chapters, forewords and guidelines.

Out-of-hours services are the arrangements to provide access to healthcare at times when General Practitioner surgeries are closed; in the United Kingdom this is normally between 6.30pm and 8am, at weekends, at Bank Holidays and sometimes if the practice is closed for educational sessions.

Healthcare in London, which consumes about a fifth of the NHS budget in England, is in many respects distinct from that in the rest of the United Kingdom, or England.

Patient choice is a concept introduced into the NHS in England. Most patients are supposed to be able to choose the clinician whom they want to provide them with healthcare and that money to pay for the service should follow their choice. Before the advent of the internal market, in principle, a GP could refer a patient to any specialist in the UK. When contracts were introduced in 1990 these were called extracontractual referrals. From 1999 the concept of Out of Area Treatments was developed. These referrals were not necessarily related to choice made by a patient. Specialised treatments were not, and are not, available in every area.

Professor Nick Harding OBE BSc FRCGP FRCP HonMFPH DRCOG DOccMed PGDIP (Cardiology) SFFLM, born 21 December 1969, is a British general practitioner and Chief Medical Officer at Operose Health.

Patient Online is an NHS England programme to encourage GPs deliver the British government’s promise to give patients in England access to their GP records and to let them book appointments and order prescriptions online.

In Practice Systems Limited (INPS) is a health informatics company, part of the Cegedim group and based in the United Kingdom.

In 2005 the National Health Service (NHS) in the United Kingdom began deployment of electronic health record systems in NHS Trusts. The goal was to have all patients with a centralized electronic health record by 2010. Lorenzo patient record systems were adopted in a number of NHS trusts. While many hospitals acquired electronic patient records systems in this process, there was no national healthcare information exchange. Ultimately, the program was dismantled after a cost to the UK taxpayer was over $24 billion, and is considered one of the most expensive healthcare IT failures.

A Primary care network is a structure which brings general practitioners together on an area basis, possibly with other clinicians, to address chronic disease management and prevention. In 2022 the term is used in England, Singapore and Alberta.

References

  1. ↑ "Directed Enhanced Services". nhsemployers.org. Archived from the original on 11 May 2006. Retrieved 11 May 2006.
  2. ↑ Pulse (28 March 2008). "COPD and smoking indicators among clinical QOF changes". Pulse News. Retrieved 9 May 2008.
  3. ↑ "Calculating Quality Reporting Service (CQRS)". systems.hscic.gov.uk/cqrs. HSCIC. Archived from the original on 1 December 2014. Retrieved 1 December 2014.
  4. ↑ Simpson, Colin R; Hannaford, Philip C; McGovern, Matthew; Taylor, Michael W; Green, Paul N; Lefevre, Karen; Williams, David J (2007). "Are different groups of patients with stroke more likely to be excluded from the new UK general medical services contract? A cross-sectional retrospective analysis of a large primary care population". BMC Family Practice. 8: 56. doi: 10.1186/1471-2296-8-56 . PMC   2048961 . PMID   17900351.
  5. ↑ Timmins, Nicholas (2005). "Do GPs deserve their recent pay rise?". BMJ. 331 (7520): 800.1. doi:10.1136/bmj.331.7520.800. PMC   1246073 . PMID   16210280.
  6. ↑ "NHS Pay Modernisation: New contracts for general practice services in England". National Audit Office. 28 February 2008. Retrieved 1 June 2014.
  7. ↑ McGovern, M. P; Boroujerdi, M. A; Taylor, M. W; Williams, D. J; Hannaford, P. C; Lefevre, K. E; Simpson, C. R (2007). "The effect of the UK incentive-based contract on the management of patients with coronary heart disease in primary care". Family Practice. 25 (1): 33–39. doi: 10.1093/fampra/cmm073 . PMID   18222938.
  8. ↑ McGovern, M. P; Williams, D. J; Hannaford, P. C; Taylor, M. W; Lefevre, K. E; Boroujerdi, M. A; Simpson, C. R (2008). "Introduction of a new incentive and target-based contract for family physicians in the UK: Good for older patients with diabetes but less good for women?". Diabetic Medicine. 25 (9): 1083–1089. doi:10.1111/j.1464-5491.2008.02544.x. PMID   18937676. S2CID   517824.
  9. ↑ Simpson, C. R; Hannaford, P. C; Lefevre, K; Williams, D (2006). "Effect of the UK Incentive-Based Contract on the Management of Patients with Stroke in Primary Care". Stroke. 37 (9): 2354–2360. doi: 10.1161/01.STR.0000236067.37267.88 . PMID   16873713.
  10. ↑ Nigel Hawkes. The Times. 28 February 2008. http://www.timesonline.co.uk/tol/life_and_style/health/article3449057.ece
  11. ↑ Ryan, Andrew M; Krinsky, Sam; Kontopantelis, Evangelos; Doran, Tim (2016). "Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: A population study" (PDF). The Lancet. 388 (10041): 268–274. doi:10.1016/S0140-6736(16)00276-2. PMID   27207746. S2CID   43754634.
  12. ↑ Jamie, Gavin. "\QOF Pass Notes". Commissioning Review (Summer 2016): 36–38.[ verification needed ]
  13. ↑ "CCG's break with QOF set to test integration and co-commissioning support". Health Service Journal. 16 June 2014. Retrieved 14 July 2014.
  14. ↑ "QOF suspended across Leeds to ease 'incredible strain' on GP practices". GP Online. 1 February 2017. Retrieved 10 March 2017.
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