Using QOF and Service Specifications to meet HI Needs

Rachel Foskett-Tharby

Key Points

• Know your population

• Know your gap

• Know QOF and actively manage the process

• Get the most from QOF

• Plugging the gaps

Know your population

• To do this successfully requires:

– Close collaboration between commissioning and public health

– Use of the outputs of the JSNA– Understanding of current service provision

Know your gap

• Consider in terms of:

– Life years– Access to services– Proportion of patients receiving optimal

treatment– Distribution – inequalities across the patch or

concentrated in pockets?

Know QOF

• Strengths

• Weaknesses

• Management of process

• Used effectively can impact on health inequalities

Get the best from QOF

Where should we be looking?

Four body systemsFour body systems

Heart diseaseHeart diseaseStrokeStroke

DiabetesDiabetesKidney diseaseKidney disease

One main One main mechanismmechanism

Disordered blood Disordered blood chemistrychemistry

Atheroma in blood Atheroma in blood vesselsvessels

Multiple organs affectedMultiple organs affectedOne increases risk of One increases risk of

othersothers

Common risk Common risk factorsfactorsPoor diet (fat, sugar, Poor diet (fat, sugar,

salt)salt)Lack of physical activityLack of physical activity

SmokingSmokingHigh blood pressureHigh blood pressure

Death and disabilityDeath and disability

6.2m people affected6.2m people affected200k deaths pa (38% of 200k deaths pa (38% of

total)total)17% hospital admissions17% hospital admissions50%+ of mortality gaps50%+ of mortality gaps

individual risk management

Indicators for

Individual Vascular Risk Assessment

Existing guidance and tools (eg SIGN)

NICE Guidelines (in current programme)

Unified risk assessment support system

Low RiskIndividual

maintenance plan

Med RiskManagement plan

Review 1-5 yrs

High RiskIntervention

Eg statinReview yearly

DiseaseExisting clinical

pathways

4.0%

20.0%

4.6%

2.7%

10.9%

3.8%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Coronary HeartDisease

Hypertension Diabetes

Expected v Registered Prevalence of major QOF conditions

PCT Registered

PCT Expected

CHD 8 - % patients whose last measured cholesterol <= 5mmol/l (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception Coded

CHD 6 - % patients whose last BP reading <= 150/90 (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception Coded

DM 20 - % patients whose HbA1C <= 7.4 (measured in last 15 months)

0%

20%

40%

60%

80%

100%

Practice code

Target Met Target Missed Exception coded

How to add value to QOF CHD (with thanks to NST)

• Calculate an ‘expected’ prevalence of CVD by practice and compare with numbers on registers

• Have strict criteria for exceptions and exclusions from registers for QOF purposes

• Audit records of excepted and excluded patients

• Ensure excepted patients have a care plan

How to add value (2)

• Establish from QOF scores which practices are not claiming full points for CHD5, stroke 5, CHD 7 and stroke 7

• Establish from QOF scores practices with scope to improve overall effectiveness of clinical practice e.g. CHD6, stroke 6, CHD8 and stroke 8

• Audit practices claiming maximum points to verify outcomes

How to add value (3)

• Promote systems of medicines management and patient adherence to therapy based on active assessment and appropriate support based on cultural and language requirements

• Ensure referral of newly diagnosed angina patients for exercise testing and specialist assessment

• Consider linking to PBC plans and bonus payments

QOF and APMS Contracts

• In groups discuss:

– Strengths of using QOF in these contracts– Weaknesses of using QOF in these contracts– Risks and benefits of setting points targets as

part of a contract– Strategies to manage these

Plug the gaps

• Identify areas not covered by QOF of local significance in terms of HI

• Identify ‘hard to reach’ populations

• Consider evidence based service framework

• Link to PBC plans

Service Frameworks

• Templates available at www.primarycarecontracting.nhs.uk

• Suggested frameworks available for:– Alcohol– Obesity– Long term conditions– Support for self-care– Sexual health

Discussion and Questions