uk experience with the quality and outcomes framework
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UK Experience with the Quality and Outcomes Framework. John Hutton IQ Annual Meeting, Hanover February 2012. Background. UK General Practitioners (GPs) are private contractors to the NHS for primary care services - PowerPoint PPT PresentationTRANSCRIPT
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/