Changing the thresholds - shaking it all about

The third thing that the QOF Advisory Committee dealt with was possible changes to the thresholds for existing indicators. These are the triggers for payment in the clinical indicators. Briefly practices start getting paid when their achievement in a given indicator reaches the lower indicator (currently 40% for everything except MH 6 and DEM 2 where it is 25%). They gain points smoothly until the upper threshold at which they gain the maximum points. Maximum thresholds current vary from 50% to 90%.

The committee does not seem to have approached this task with any great enthusiasm. However the the potential changes in thresholds are the most significant aspect of the whole of its recommendations so far. Practices have been excellent at hitting the targets already set. The committee noted that on the only occasion that thresholds have been increased, a couple of years ago, there was an overall increase in exception reporting as practices became more diligent at seeking these out.

There area a lot of caveats and the committee recommend that most of the details need to be worked out in negotiations - it regards the overall effect on practices at beyond its brief. When moving the thresholds the committee has suggested this should be on a historic basis, picking a threshold that would have previously been missed by half or three quarters of practices. This has the strange effect that success will be met by things becoming harder and failure in an indicator will result in it being easier. There will be a disincentive to achieve anything above the upper threshold although I would expect this effect to be mild.

There is also a proposal to change the bottom threshold of indicators (currently 40% for most inductors) to a level that 95-99% of practices have achieved although it is acknowledged that there is little evidence for setting at any particular level.

The practical upshot of all of this for practices is more work to get the same money, or the same work to get less money. I have looked where the centiles (1st,5th,50th and 75th) in the 2008 data are. You can see a full list of where these new thresholds would lie(Excel or Opendocument spreadsheets) . This covers one year only and the committee has suggested looking back over two but I would not expect a huge difference. No indicator gets easier to achieve and many - even at the 50th centile - get much harder. I have not yet modeled the changes at practice level, things are still a little uncertain, but this could be similar to the square root loss in terms of its effects. Even the Advisory Committee notes that the losses are more likely to be concentrated in more deprived areas and may increase health inequalities.

The effects of these changes will not only make many indicators harder but also make the framework more complicated. All of this now passes to the negotiators and we wait to see what is agreed. Personally I think it unlikely we will see much change in the lower threshold. The upper threshold is likely to be much more fluid.