QOF News

I am grateful for an email pointing me to some work done to try to predict the prevalence of QOF related diseases. The prediction is based on the age, sex, ethnicity, deprivation and smoking status of a practice's population. Readers with long memories may remember something similar being done by the North East Health Observatory a few years ago. This new work, however, covers more disease areas and is rather easier to use as the predictions are now featured on NHS Comparators (that link only works on NHS computers, sorry)

The methodology is interesting as the "expected" prevalence is based on various household surveys rather than GP data. The national prevalences are all rather lower than the "expected" prevalences except for cancer. The high relative prevalence of cancer in the QOF data is likely due to the predictions being based on one year and QOF registers being based on several years.

It is possible to argue with the methods of determining prevalence. It is not entirely clear that it is desirable that medically recorded prevalence should be the same as some of these surveys. Data about pratice populations is generally limited to age and sex and so various assumptions and approximations have been used in the model with data from other sources. Whilst there is some validity in these objections they do not justify writing off this work. For the first time at an accessible national level there is an attempt to produce corrected prevalence figures for practices. Comparison of one practice with another is still not simple but it is a little simpler. It is only thing that has made me log on to NHS Comparators recently.

The Marmot report on health inequalities, published a couple of weeks ago, had a few things to say on the subject of the QOF. Somewhat unsurprisingly it suggested that the QOF is used to reduce inequalities. One of the ideas mentioned, although not an official suggestion, was removing the upper threshold on QOF targets. I have to admit some sympathy to this idea in principle although it would certainly add to my work as a GP and the benefits are not entirely clear cut.

There are, however, a number of practical problems which could make implementation hard.

The biggest problem is one of funding. Currently practices receive a certain amount for each patient that meets the criteria between the lower threshold (currently mostly 40%) and the upper threshold (anywhere from 50-90%). If we want to expand that top threshold up to 100% there are a couple of ways of doing this. First we can keep the number of points the same. This means that the incentive per patient falls but the total potential cost to the government remains the same. Where thresholds are at 90% the difference will be 15% - enough to make some unhappiness but probably not earth shattering.

For DM 23 (diabetics with HbA1c less than 7) each patient will be worth a sixth of what they were before.

The other option is to keep the payment per patient the same. This is a lot more costly for the government. DM23 would need 102 points allocated to it (it has 17 at the moment) to keep up the incentive.

None of this takes account of exception reporting. As thresholds have not risen in this way before. It seems very likely that exception reporting would rise, but by how much? Would it incentivise exception reporting more than achievement? Might it simply lead to more organised exception reporting systems to send out the three letters? Most practices already get quite well over thresholds without the incentive of extra points.

And would it really reduce inequality? Could it make it worse? In the first years of the new contract practices in deprived areas did rather worse than those in less deprived areas, however they later caught up. Two years ago when moving the thresholds was mooted before extended hours came in I did some of the maths. It seems effects on practices are likely to be marginal only, but we won't know until it is implemented.

So not an absolutely awful idea but a lot of work would be needed before implementation.

There is more reaction reported at GP magazine.

I apologise for the unavailability of the main site. This is due to upgrade work by the hosting provider which is not going all that well! This blog moved to a different server a couple of days ago. Should be up again soon and we are promised better, faster stronger etc.

Setting indicators is difficult. It is especially difficult setting indicators attached to incentives as they are in the QOF. It is especially difficult to produce indicators that actually produce the result that you are after without producing perverse incentives.

Required reading for anyone setting a target at any level, from practice to nationwide, should be the very readable report from the King's Fund report Getting the Measure of Quality. It clearly documents the successes and potential failures of information gathering and some of the possible remedies. It would certainly be interesting to see some of these standards applied to QOF indicators although there are signs that the new NICE committee is thinking along broadly similar lines.

I have written a guide to coding in QOF for Pulse Magazine. The brief was for 1000 words so it is fairly concise. You can find it here (free registration required).

All four countries' QOF data is now on line at the QOF Database. All of the data is also on the download page in both CSV/SQL format and also as a complete Microsoft Access database.

The publication of the Irish data was a little bit limited so you may notice that there is no palliative care data for Northern Ireland and the patient survey data is limited to the scoring range. Other than this the data is complete.

Wales joined England this year in not including all of the practice names and addresses so these may be a little out of date where practices have moved recently.

I am delighted to be able to announce that the English and Scottish QOF data is now online. The Welsh and Northern Irish data was published by their departments of health today and I hope to have this online by Wednesday or Thursday. Downloads to follow at the end of the week but I will send another email when everything is on.

Results of the QOF seem to be roughly comparable to last year with the loss of points to practices coming from the survey results.

There are a couple of things to note in the data. Quite a lot of the Scottish data, particularly in mental health, has been held back due to small numbers causing a risk of confidentiality breach. Whilst this is right and proper it can be a little frustrating.

England did not release a full address lookup table this year (and later in the week it will become apparent that Wales has not either). I have used addresses for previous years and everything should work fine. Addresses may be a little out of date. If you work at a practice with incorrect details and have and "old style" NHS email address which features your practice code e.g. fred-blogs@gp-X99999.nhs.uk then you can correct this. If you corrected details last year these remain intact.