QOF News: site news

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.

I am delighted to announce a new feature on the site about which I am quite excited although I must admit may disappoint a lot of you.

Over the past couple of years I have received a steady trickle of emails about practices with incorrect details on the database. This can because practices have moved, merged, or changed hands. Commonly it is due to not terribly good details in the first place. It can be impossible to tell one practice from another within the same building in some cases.

Other emails have pointed out that this site appears rather higher in the rankings of search engines than their own website which caused confusion amongst users.

The answer is to allow practice to update their own details. This can be more easily said than done however. It required quite a bit of messing around in the entrails of the site although the same process has given a more intelligent search form.

The really difficult bit is trying to unsure that only practices can change their details. Somewhat to my surprise the NHS IT people have not yet provided a reliable way of making sure that a GP's identity on-line is who they say they are. The closest I can come is the old style email addresses in England which contained the practice id as part of the address. For many practices, even with nhs.net addresses this old address will still work. For practices outside England so such system has ever existed to my knowledge.

So please have a go if you can, and my apologies if you cannot. Suggestions for an on-line verification scheme for other practices gratefully received!

It has been announced that from next year the square root formula for calculating the cash due per point in the clinical areas is to be abandoned. In brief this meant that the cash per point rose as the square root of prevalence rather than linearly with it. The theory was that there would be an economy of scale enjoyed by practices. For more information on this use the search box above to search for square root. Over time thought has moved against this theory.

In the following year the 5% cut off will go. Previously practices with less than five percent of the maximum prevalence would be treated as if they had exactly five percent of the maximum. This could create some bizarre results.

I have been asked by many people over the past couple of weeks what the effect on practices would be. Well after having a short holiday I have looked at modeling these changes based on last year's data. Before I discuss the results a couple of warnings about all that is to follow. It is a model, not a prediction. It is based on applying next year's rules to last year's data. It assumes that all of the indicators will remain the same - which is simply not true. It assumes that practice behaviour is identical which is unlikely. I have also had to make estimates at the prevalences of smoking and depression screening which were not published for England this year. These are likely to be close but not exact. I am not using the Dep 2 indicator at all. This is a model and not a detailed estimate - but it should be close.

So on with some meat. The figures for each practice are available from the left hand menu of each practices page. These are expressed in terms of the equivalence number of points gained and lost. To get the overall picture you can see the spread of practices in the graph above (I have taken eight outlier practices off the top to make the rest of the histogram clear - they tend to be unusual practices and so have unusual patterns of prevalence).

We can also look at practices in groups. Perhaps the most obvious group to look at are University practices. Dealing with younger people they tend to have a lesser incidence of chronic disease - particular cardiovascular and pulmonary diseases which dominate QOF. A rather crude search shows 26 practices in the database with the string "Univ" in their address. On average these practices lose 234 points equivalent from their QOF payments. These were the practices that started from a very low base so to lose this amount is very significant. In fact after these changes their take home points from the entire clinical domain is an average of 93. Their clinical domain is less valuable to them than the patient experience domain. This is likely to have a very significant effect on these practices.

We can also look at the effect at PCT or Health Board level. You can see the PCT level changes online or download a (7k) csv file. The winners and losers are quite dramatic. London is hit hard with both Lambeth and Westminster losing the equivalent of over 100 "full price" points per practice. The clear winners are in the North of England or attractive seaside resorts or, in a couple of cases, both. Two PCTs gain over 100 points per practice. County Durham PCT is going to have to find another one and a half million pounds per year to cover the cost of these changes. Meanwhile in Lambeth eight hundred thousand will be taken from primary care. Of course both of these could be told, more optimistically, the other way around! The message here is that although this change may be cash neutral at the national level the same is not true at the PCT level.

As the graph above shows we have a normal distribution. These changes will be moderate for most, large for some and extreme for a few - a couple of practice gain over a thousand points although they are not large but small and specialist practices.

Another year has passed and there is a new set of QOF data to pore over. Northern Ireland published first this year about a fortnight ago whilst Scotland and England both published last Tuesday. All of the data for these countries is now online at the QOF Database. You can search for or browse the data.

I will publish the Welsh data when it becomes available. Database download will also be available soon as will overall prevalences.

Palliative care data is not visible yet either. This is due to differences in the way that this has been reported. England gives a prevalence, the other countries just give a yes or no to the presence of a register. This will take a couple of tweaks to display sensibly and I will do this soon. In any case the prevalence is difficult to make a lot of sense of. These tend to be small numbers which inevitably vary quite considerably over time.

In other site news I have removed the links to the QOF changes pages as these have become out of date as well as the extended hours calculator. In the latter case the national directed enhanced service is much less relevant as many local enhanced services filled the gap caused by its tardy arrival.

For the future I am working on ways of keeping practice data up to date, particularly addresses. I also hope to bring in links to practice websites. As I am a one man band and there are about ten thousand practices automation is going to be essential and this is taking a little time to code. It is likely to come in gradually.

If there is one thing that QOF has taught us it is that most GPs respond to a challenge. In the first year the government was surpised at the levels of achievement seen, although this was largely a repeat of the situation with Item of Service payments in the 1992 contract. GPs it seem, will do what is required to meet the contract.

We may have met our match, however. When the requirement is largely that you are not a GP but a large corporation it is an impossible target to meet. With hundreds of individual and different contracts it also become impossible to collect consistent statistics and monitor the performance of the corporate clinics - just when we seemed to be getting started on that problem.

We have seen this already with independent treatment centres. For years there was a persistent rumour of poor outcomes from these centres but no good figures to back these rumours up. There is some data now which suggests that there is little difference in outcome from NHS centres but nobody benefited from a five year delay in collecting the statistics.

We risk a distraction of GPs from the patient sitting in front of them and their needs by the central declaration of needs and solutions from central government. Anything else is a risk to the patients in primary care. This is why I support the Support Your Surgery campain.

Since the new indicators appeared on the site last September the chart of prevalence on the practices page has been pretty awful. It was almost impossible to read the key at the bottom. This was a major limitation of the charting app I was using.

Well now there is something new. Thanks to the rather wonderful Fusion Charts there are now simple and clear charts. The downside is that they do need flash. However the way they work means it will be much easier to add new charts to the site in the future without a huge amount of extra work for the server to do.

Enjoy.

A couple of weeks ago the BMA issued its guidance on the QOF changes for this year. Basically some organisational areas were cut and the points transferred to two new areas to be based on surveys of patients.

The survey questions seem likely to be very similar, if not identical, to those asked about appointment booking in the 2007 patient survey.

As we have some data to go on, for England at least, the effect of the changes can be modelled at practice level. In fact I have done this for all practices in the UK, simply the results are likely to be less reliable outside England. In particular the square rooting of the COPD prevalence is based on the English average - slightly overestimating losses outside England.

To find the data for individual practices just use the search or browse pages to find the practice and then select from the menu on the left side.

I have changed the search system slightly to (hopefully) give better results. Previously you could use wildcards e.g. Car* would give Carlisle and Cardiff. This was hardly ever used and the search tended to give very long lists of unhelpful results.

You now can't use wildcards but the results should be better. For more general QOF queries over many web sites the Google search is still there. It searches on selected QOF related sites without all of the stuff about GnuCash and Hebrew characters you tend to get on a full Google search.

In the fast(ish) moving world of GP contract negotiations the finances of the extended hours DES have changed again. In his latest letter to the profession Lawrence Buckman has announce an increase in the rate of payment from £2.80 to £2.95 per patient for extended hours. It has also been clarified that the survey will be in QOF and not part of the extended hours DES

This is in general good news - there is more cash for providing extended hours under the DES although and this is surprisingly substantial for many practices. I have updated the extended hours calculator which can be accessed from left hand menu the practice pages.

I have also corrected a bug which overestimated the hours required for about one in six practices. Sorry about that and thanks to the eagle eyed reader who spotted it.

The contents of the DES are still far from fixed as you can see here and here.

It has been a busy few weeks. Just as I was starting to digest a report suggesting the development of the QOF then the negotiations for changes to next year's GMS came crashing to a halt. The report is still worth reading, if only for the summary of research done with QOF data thus far.

There is a pretty good summary of the situation in a letter from Laurence Buckman - chair of the GPC which I would recommend reading. In summary, for the impatient, the government (only in England for now) is imposing changes to the contract to move cash from QOF and Choose & Book and put it towards increased hours of availability. This, we are told, its only priority for primary care this year. Arguably this is a move from quality to quantity

As far as QOF is concerned several indicators are to be removed taking with them a total of sixty points.

• Holistic points (20 of them) - points for consistency - all gone
• Records 3 (1 point) - communication with out of hours service
• Education 4 (3 points) - induction training for new staff
• Management 2 (1 point) - computer back up
• Management 4 (1 point) - instrument sterilisation to national standards
• Management 6 (2 points) - job description for all new posts
• Management 10 (2 points) - employee procedure manual (absence, bulling etc)
• Medicines 4 (3 points) - repeat prescriptions in 72 hours - 48 hour target remains
• Medicines 11 (7 points) - medication review for patients on four or more medications (review for all patients remains)
• CS 5 (2 points) - there is a system for inform women of smear results
• CHD 12 (7 points), Stroke 10 (2 points), DM 18 (3 points) and COPD 8 (six points) - flu jabs in high risk groups

As there are 1000 points in the QOF a rather obvious bit of maths shows a 6% drop already. There is more, however. Initially the scoring area for each of the indicators started at 25%. This was increased two years ago to 40% and this new imposition will increase it to 50%. The top thresholds for payment will also be increased to something around the mean of current achievement. This second part is likely to be more significant for most practices. Pretty much by definition half of practice would be expected not to hit this higher threshold.

The effect of all this remains to be seen. We already know that exception reporting tends to be reactive - i.e. there is more exception reporting when below the threshold than above it. This is largely because practices stop reporting when they get over the threshold. It would not be unreasonable to expect a bit of an explosion in exception reporting with these changes. Of course there will almost certainly some increase in achievement but the extent is uncertain.

We can use the data we already have to try to model the effect of these changes - and apply them to last 2006/7 data although with the caveat above. This should be online in the next day or so.

The QOF data for Wales in 2006/7 is now available. It actually came out about six weeks ago but I missed it at the time and heard via a reader last week.

This completes the data for 2006/7 although I do still need to update the downloads section of the site over the next couple of days.

The English data is now on the QOF database joining the Scottish and Northern Ireland data which has also been tidied up a little. The English data was a little delayed by the postal strike eventually arrived safely.

There are a couple of "virtual" indicators, largely relating to prevalence. I have created two depression indicators relating to the prevalence of people requiring screening for depression and those who have a history of depression recorded in the past. I would avoid putting too much weight on the latter as historical coding may be really quite variable between practices. In fact as practices were not specifically working towards these virtual indicators they should all be used with some caution.

I have also been asked about smoking prevalence. There is therefore a virtual indicator here too. Here it relates to the number of smokers amongst those covered by the smoking area (those with CHD, LVD, stroke, asthma, COPD and hypertension) who have been asked. This is not the only way to do it and is purely a judgement call on my part. In particular it may not correlate with some of the "official" registers and is not the one used for payment.

You may also notice that I do not put prevalence information for the palliative care domain on the main prevalence list. For one thing this prevalence is not used for payment. Secondly the numbers are generally so small as to be unreliable and thirdly they are so small they are suppressed for confidentiality reasons in many cases by the departments of health.

There are about half a dozen English practices without names or addresses. There was not a comprehensive look up table included with the English data this time so I have used several different sources. I will try to correct these in time.

Finally we are still awaiting the Welsh data. I have heard nothing official but will keep asking!

Although we don't have full practice level data for Wales and England yet there is some national level data. We can work out prevalence in all four of the countries and for the UK as a whole. They are listed below. Smoking is not in the table as it is not listed at the national level but should be available when the practice level data comes through.

On the subject of practice level data there is some more information on the information centre website. They are planning to send out CDs so I will apply for one. Unfortunately there is a postal strike over the next week which may affect delivery somewhat. There should certainly be some demand. The 2006 full data database has been downloaded from this site over eight hundred times.

No news from Wales as yet.

	England	Scotland	N Ireland	Wales	UK
Asthma	5.78%	5.48%	5.75%	6.53%	5.79%
Atrial fibrillation	1.29%	1.27%	1.25%	1.61%	1.30%
Cancer	0.91%	0.92%	0.79%	0.93%	0.91%
Chronic kidney disease	2.39%	1.82%	2.44%	2.28%	2.34%
COPD	1.43%	1.86%	1.53%	1.94%	1.49%
Coronary heart disease	3.54%	4.55%	4.18%	4.28%	3.67%
Dementia	0.40%	0.55%	0.52%	0.42%	0.41%
Depression Screening		7.24%	7.50%	7.56%	7.39%
Depression Ever		6.25%	6.13%	7.27%	6.55%
Diabetes mellitus	3.66%	3.52%	3.17%	4.21%	3.66%
Epilepsy	0.60%	0.72%	0.74%	0.73%	0.62%
Heart failure	0.78%	0.88%	0.81%	0.51%	0.78%
Hypertension	12.51%	12.61%	11.68%	14.26%	12.58%
Hypothyroid	2.55%	3.14%	2.90%	3.13%	2.63%
Learning disabilities	0.26%	0.41%	0.32%	0.30%	0.28%
Mental health	0.71%	0.79%	0.75%	0.72%	0.72%
Obesity	7.42%	7.01%	8.38%	9.64%	7.53%
Palliative care	0.09%	0.10%		0.10%	0.10%
Stroke and TIA	1.61%	1.97%	1.62%	1.97%	1.66%

The data for Scotland and Northern Ireland was released last Monday and is now on the site. It has been a little more awkward uploading the data this year due to the changes in the areas and the appearance of areas without prevalences (palliative care) and depression having two different prevalences. I hope this makes some sense when viewing the data but nothing is set in stone and bright ideas welcome!

Wales also released some data this week but this did not go down to practice level and is therefore not particularly useful for many purposes. The statistical release was described as release one so there may be more although the site also suggests that there will not be an update for a further year. I am enquiring about further data.

Even more oddly is the English data. The Information Centre has spreadsheets of data at national, SHA and PCT level but not practice level. Practice level data is available but only one practice at a time through their own web interface. I have emailed them asking about spreadsheets but have not year heard back. In fairness they were probably quite busy on Friday.

I will keep you informed about their replies.

I do get asked quite a bit when the new data is due to come onto the site. Well all the data comes from the various departments of health in the four countries. The current plans from England and Scotland are to release the data sometime in September. Something of a relief for me, at least, as I have to get all of the new data into the database.

As an aside the English GP patient survey 2007 has been released. As this is down to practice level and is in a reasonably friendly format I will try to put this onto the site in addition. It also includes interesting figures such as rurality (really horrible word!) and deprivation factors. For largely presentation reasons however this is unlikely to precede the full QOF data (it will be linked from the 2006/7 QOF data).

The site will be down for about half an hour after 10pm on the 26th of March for those nice people at Mythic Beasts to do some essential work on the server. Sorry!

I have been doing a little bit of work around the site over the last couple of weeks and the changes are now ready to be formally announced.

The first is this blog, which allows more frequent updates than the email alerts. The email alerts will continue as before as an infrequent alert to a data update.

There is also a new custom Google search function available on the search page. This will search QOF related sites specifically. Any suggestions of additional sites would be appreciated.

There is some improvement to the data on the site for 2005/6 - partly in the Scottish data which now includes there September update and some corrections of obvious errors in the Welsh data.

And finally over on DH Consultation Feed site there has been a complete rewrite of the plumbing to make it more reliable. This site offers takes the DH consultation page and repackages it as an RSS feed. A limited audience perhaps but useful to some!

There is quite a lot about the Quality and Outcomes framework that needs a home. There are, for instance, changes in the rules or announcements of prevalence figures that don't get to feature in the main dataset but may well be of interest to people browsing the site. This will also be a home to other bit of QOF information that I have written from time to time and have again lacked anywhere decent to put them.