QOF Consultation Response

The Deparment of Health have launched a consulation on "Role of incentive schemes in general practice". You have until one minute to midnight on the 7th of March to submit any comments you have, and please do so. I have copied my response below. Most of this was written before submission and so there are a couple of cases of free text where there was not a box to put it in.

Do you agree or disagree that incentives like QOF and IIF should form part of the income for general practice?

Agree

The QOF, and to a considerably smaller extent, the IIF, have contributed to a rise in data quality and some measures of quality of care. They should be considered together with Enhanced Services as part of the funding of general practice.

Whilst QOF and IIF are considered incentives and enhanced services (ES) are considered as commissioned this is not a distinction that survives to the provider level. If a commissioned service payment or an incentive payment is less than the cost of providing the service, then there will not be a business case for the practice to provide the service.

IIF has not proven successful and has been largely retired this year. If it survives, then it should be included in a single framework with ES and QOF. All of these must be considered within a larger commissioning framework. It makes little sense in the current contract that a single process can be paid through several different mechanisms.

Do you agree or disagree that QOF and IIF help ensure that sufficient resources are applied to preventative and proactive care?

Disagree

Most of the QOF is based around care of chronic conditions and the secondary prevention of complications of chronic disease. Public health measures and primary prevention have not been successful when these have been tried previously.

It should be considered a chronic disease management framework. Proactive care can be tackled in annual checks, but this is management of disease rather than prevention. There is an element of secondary prevention here but this has not been proven in rigorous studies.

Public health measures can be, and are, commissioned through enhanced services.

Would relative improvement targets be more effective than absolute targets at delivering improvements in care quality while also addressing health inequalities?

No. I would disagree strongly here.

Differential targets would appear unfair to practices and introduce perverse incentives which could be damaging to patient care.

Relative improvement targets would mean that practices could be paid different amounts for the same work. This would be unfair on practices. For the majority of QOF indicators practices start from zero at the beginning of the QOF year and build their achievement throughout the year until the following April. It is not the case that practices start from a higher level if they have had a higher level of achievement in the past, although they may have better processes in place.

This would also act as a brake on innovation. Practices which target work at a disease area and increase achievement in areas that subsequently become introduced into the QOF would be penalised with higher thresholds. Where an indicator remains in QOF for a few years then practices may be incentivised to vary their achievement from year to year, perhaps on a two year cycle, to maximise income.

The introduction to this question mentions an upper threshold of 85% leaving 15% of patients without incentives attached to them. The simplest solution is to move the upper threshold to 100% whilst leaving the lower threshold and the gradient the same. The main reason for not doing this would be the increased funding that may be required. There is no compelling reason to leave that 15% of patient without incentive.

If the upper and lower thresholds are too close together then this may reduce the incentive for practices and generate perverse incentives. In the current QOF the range between lower and upper thresholds for childhood vaccinations is small, although it has increased slightly in the most recent year. For practices with low achievement there is little incentive as they could have little chance of reaching the lower threshold. High performing practices also have little financial reason to improve. For other practices, the incentive is low for many patients but the patients between the thresholds can be worth hundreds of pounds each.

There are, of course, differences in populations and locations for practices which will influence how easy it is to deliver care. This is dealt with currently with a prevalence adjustment which will vary payment according to the specific disease burden. Adjustments for other social factors are properly contained in the global sum adjustment, although this has not been reviewed for nearly 20 years. Adjustments cannot reasonably be incorporated into an incentive scheme.

In what other ways could we use incentive schemes to address health inequalities?

Inequalities happen at a personal level and contracts operate at a practice level or above. Reconciling the two is likely to be very difficult. Solutions, such as prioritising practices with harder to reach populations is better done at the global sum level. Practices are unlikely to be willing to offer a differentiated service to different groups of registered patients.

There is potential for target enhanced services with specific focus but this should not be part of IIF or QOF.

To what degree, if any, do you think that ICBs should influence the nature of any incentive scheme?

Integrated Care Boards should be consulted on a national framework. This should be the core of any scheme. There may be potential to use a menu, as was the case of National Enhanced Services, but this is likely to be small.

There has been some attempt at local commissioning with Enhanced Services which, as I discussed earlier are broadly equivalent to QOF at the provider level. These varied in quality due to inexperience of commissioners. They have suffered from poor infrastructure support. The use of a menu of nationally supported services may help in that specific area.

There will always be practices at the geographical edges of ICBs that will have services which vary with their neighbours. There may be a perception of unfairness there and there may be a negative impact on services which are not incentivised in a particular area. They could be considered uncommissioned.

Do you agree or disagree that a PCN-level incentive scheme like IIF encourages PCN-wide efforts to improve quality?

Agree, but only to a small extent.

Incentives will work best if they are closer to the person whose behaviour you are trying to influence. PCNs are effectively a management structure so there is some sense in applying incentives there if it is the management that you are trying to influence.

PCNs are not the most efficient way to incentivise individuals – especially as some PCNs can be extremely large and incentives somewhat distant from clinicians.

What type of indicators, if any, within incentive schemes do you think most help to improve care quality? (Select all that apply)

Clinical coding (for example, accurate recording of smoking status in a patient record)

This is an effective use of incentive but the effect on care quality is not clear.

Clinical activity (for example, undertaking an annual asthma review)

This is probably all that you can do.

Clinical outcomes (for example, stroke rates)

Clinical outcomes are much too far removed from activity to be an effective incentive. We have mild version of this problem in the current QOF around shingles vaccination where there can be a decade between the incentivised action and the incentive being paid. This may be to someone else entirely, even in a different practice. It is also practically quite difficult to deal with the effects of patient death or emigration (in the latter case that would include moving to Scotland, Wales or Northern Ireland)

Quality improvement (QI) (for example, local project to improve patient experience or staff wellbeing)

This becomes so vague as to just be a commissioning effort which is better dealt with in an ES. These are pure process box ticks.

Do you think there is a role for incentives to reward practices for clinical outcomes measured at PCN or place level?

No

The incentives become so detached from the individual action that they cease to be incentives. Keep the incentive close to the person taking the action.

Do you agree or disagree that there is a role for incentive schemes to focus on helping to reduce pressures on other parts of the health system?

Neither agree nor disagree

The likely effect of any improvement in patient care is a reduced pressure on the health service but this should not be the primary motivation for this – that should be patient health. That is also likely to be a variable outcome which will only be apparent with large numbers of patients and difficult to attribute to any single actor.

Do you agree or disagree that incentives should be more tailored towards quality of care for patients with multiple long-term conditions?

Neither agree nor disagree

Whilst the aim is laudable specific indicators are likely to be difficult to create. They can end up being so vague as to be useless. They tend to say “do a review”, from which is very difficult to establish any evidence of benefit. The evidence for specific interventions in multimorbidity are poor.

Do you agree or disagree that patient experience of access could be improved if included in an incentive scheme?

Disagree

Creation of standards in this area would be very difficult in a way that is equitable. Of note is that there has been an attempt in this area in the past in the Patient Experience indicator. From 2009 to 2011 the PE 7 indicator was based on the number of patients who responded to the GP practice survey. This indicator did not last as it was not felt to be effective.

Any change patient perception of access is likely to require substantial resources, and this may be more that would be appropriate to commit to an indicator. Any real incentive is likely to require substantial change to the contract including payments for each type of patient interaction or appointment. Whilst this may be a direction that NHS England would wish to consider it is not something that would be part of an incentive framework.

Do you agree or disagree that continuity of care could be improved if included in an incentive scheme?

Disagree

There is no current indicator to measure continuity of care. Even survey results and patient perceptions have not been validated as measures. Any incentive payments could have the potential to produce unexpected incentives or results.

Any proposed indicators here would need to be piloted but the chances of producing a simple, clear and specific indicator are small.

Do you agree or disagree that patient choice could be improved if included in an incentive scheme?

Disagree.

Once again, the production of an effective indicator is likely to to be very difficult. Choice is often provided at referral management centres which are managed by ICBs. Wherever it happens it is difficult to measure. Choice is likely to vary significantly between different areas of the country. Choice is easier in areas with higher densities of providers. This will be an area that is better dealt with at the ICB level.

Do you agree or disagree that the effectiveness of prescribing could be improved if included in an incentive scheme?

Agree

Prescribing is an area that has been the subject of indicators in both the QOF and IIF in the past. A stable multi-year approach is most successful – incentives for practices to change are higher if there a snowball effect on treatment. We have seen this effect in QOF around the use of statins and the use of medication in left ventricular systolic heart failure.

An example of how this does not work was the transfer to edoxaban which was included in the IIF in 2022/23. This was a purely financially driven indicator which was dropped after a year as the financial situation changed. The changes from this indicator were quite small. 

Prescribing data from OpenPrescribing

If you think there are any other areas that should be considered for inclusion within an incentive scheme, please list them here.

There is some potential for safe prescribing measures to be used. This is mostly avoiding things so would effectively be an “upside down” indicator where a lower percentage is scored more highly.

What opportunities are there to simplify and streamline any schemes for clinicians, and reduce any unnecessary administrative burden, while preserving patient care?

The best way to avoid “tick box” indicators are simply not to introduce them in the first place. Whilst there are many aspects of practice that it might be considered desirable to incentivise in practice it is important to also consider the quality of the indicator for that area. An important area with poor quality or indirect indicators should not be included – other contractual mechanisms should be used to deliver these improvements.

The difference between item of service payments and incentive payments is small and there is they should be considered in the same way. Bringing all performance related searches and payments, including immunisations, into a single framework would greatly reduce the boxes that need to be ticked. For example, there are currently four or five payments linked to influenza vaccinations which are claimed through three different systems. This is time consuming, costly to administer and entirely unnecessary.

Are the new indicators worth doing?

Readers of the Autumn issue of GP Business may have seen my calculations of the amount of money payable for meeting each of the current QOF indicators. Although there were huge variations the majority of indicators seem to have been worthwhile from a financial point of view.

In a letter to GPs in England the GPC has urged practices to review whether it will be worthwhile taking part in all of the new indicators.

Where some of these areas, such as rheumatoid arthritis, are completely new it is very difficult to predict the potential rewards.

There are a couple of areas that are easier to estimate, and the headline seems to be that these are greatly underfunded.

Three points are proposed for an annual dietary review in all patients with diabetes. Special training may be needed to allow a GP or nurse to conduct this review. In Scotland it has been confirmed that no further training is required.
The payment for this review will be around £1.55 if the practice reviews ninety percent of patients with diabetes. Even using the costings used by NICE there is only three minutes or so of nursing time available - even less if extra training is required. There is very little detail about how long that this expected to take, but this would seem quite a short time.

The estimates are similar for the annual exercise questionnaire for patients with hypertension. GPs in Scotland will be glad to know that these indicators do not apply to them, having been declared unworkable in negotiation with the Scottish government.

The General Practice Physical Activity Questionnaire (GPPAQ) is fiddly to score and will have to be applied to every patient with hypertension less than 75 years old. If we fairly conservatively assume that this would mean half of all patients on the hypertension register (it is closer to 70% in my practice) then this will work out at around a pound per patient. This is half of the payment for the much simpler depression screening questions and would not cover the cost of a mailshot or telephone survey.

There is a follow up indicator. Patients whom the GPPAQ has assessed as “less than active” should have a brief intervention. Even saying fairly generously that half of all patients are active there are only two pounds available to deliver the brief intervention. If fewer patients are “active” then this amount falls. This would have to be very brief to make this a worthwhile activity.

In one of the strange quirks which make QOF so complicated that less success in getting patients to complete the questionnaires will increase the cash available for each brief intervention.

Practices have tended to chase every possible QOF point in the past. The very high levels of point scoring - over 97% in the last few years - suggest that practices have aimed at QOF in its entirety. The lowest levels of achievement have been where evidence has been weak and hassle has been greatest - the PHQ9 indicators.

Where there is a poor business case the GPC is right that practices should consider carefully whether it is reasonable to work towards these new indicators. Picking and choosing will be a considerable change to the way that practices approach the QOF.

Smoking indicators

The business rules for the QOF are rather murky place and I am grateful to a couple of people who have pointed out some odd things happening in the smoking cessation areas

Just as a reminder smoking cessation advice now applies to all patients in the practice who are over 15 years old and smoke. There is a difference between those with chronic disease and those without that those with chronic disease should have the advice annually (well, within 15 months of the end of the QOF year) and those without within two years (27 months). So for this year the smoking cessation advice requirements applied since January 2011, or 14 months before the business rules actually came out.

Despite fairly minimal change to the wording the actual smoking cessation indicator has changed. Two codes are now needed to pass this indicator. One code from each of the two following groups. The fist group is basically the same codes as before. The patient should receive advice or be referred or pointed to self referral to a smoking cessation clinic.

8CAL	Smoking Cessation Advice
8HTK	Referral to stop smoking clinic
8HkQ	Referral to NHS stop smoking service
8H7i	Referral to smoking cessation advisor
8IAj	Smoking cessation advice declined
8IEK	A declined code
9N2K	Seen by smoking cessation advisor
13p50	Practice based smoking cessation programme start date
9Ndf	Consent given for follow up by smoking cessation team
9Ndg	Declined consent for follow up by smoking cessation team

This is all pretty sensible. Most of the evidence points to a good smoking cessation clinic improving quit rates. However there is now a second part that requires a prescription to be issued. Note in both these areas there is a declined code. I use EMIS PCS at work and the declined codes are not yet available on the system. That is 17 months after they could first require to be entered.

745H	Smoking cessation therapy (and all its subtypes)
8B3f	Nicotine replacement therapy provided free
8B2b	Nicotine replacement therapy
8B3Y	Over the counter nicotine replacement therapy
8IEM	A declined code
Rx	Smoking cessation product prescription

Quite how this helps anything is beyond me. We have a local smoking cessation clinic that does not (or nor does it need to) inform me every time they advice someone to get some patches at the chemist. Logically the most sensible thing for me to do would be to throw patches at patients like confetti. This is likely expensive for my PCT/CCG and, in the curse of QOF, it seems that nicotine therapy may actually reduce quit rates.

Even the evidence quoted in the official guidelines is confused and muddled.

It would be nice if these retrospective changes were corrected in the next ruleset although past experience suggests that this is policy and not error and change is unlikely.

QOF indicators for 2013-14

NICE is currently consulting on the potential new QOF indicators for 2013-14. These are the indicators that could be put forward to the negotiators in the summer for consideration of the following year's contract. There is certainly no guarantee that they would go forward. This year rather fewer than half of the suggestions in the menu actually made it into practice.

As this is a consultation then the more responses the better. My response to the QOF consultation is on the web in the interests of openness. In generally the aims seem laudable although there are some significant practical problems that may arise with the implementation of these indicators. Some clearly need more work but your view may differ and I would encourage you to put them forwards.

Some of my points are missing

Yesterday the changes to the GMS contract for the year from the first of April came out. there are quite a few of them and the full details are on the BMA contract page. Of course I turned to the QOF changes first of all. You can read the full QOF changes here.

You can almost feel the negotiations behind them. Raising the upper threshold on three indicators from 70% to 71% seems likely the result of a very long and banal meeting. Other areas have other minor differences and some, such as mental health see big changes. There is also a lot of "to be announced" around prescribing and referral audits.

I am trying to write and article for a trade magazine about the changes but I have hit a problem. The numbers just don't add up.

Page one goes pretty much as billed with 92.5 points being removed. Page two then gets a little odd. CHD11 (ACEi after MI)become CHD14 with 3 extra points. DM9 (foot pulses) gains a point but also does most of what DM 10 currently doing. Is this duplicated or is there another three points lost here? So at the end of page two we have lost 92.5 or possibly 95.5 points and gained 4.

Page three - MH 9 gains four points in its split up but depression loses 20. So total 8 gained and 112.5 (or 115.5) down.

Page four has lots of new indicators so gains 40. Now 48 up.

Page five gains 48.5 but loses another 4. Final total 96.5 gained with at least 116.5 lost. 20 points have gone adrift somewhere. Even worse there may be another 3 if they don't want to pay twice for foot checks. And actually I wonder whether they will really want to have two indicators for aspirin and beta blockers in CHD which would lose another 14.

So where are my 20 points?

Updated 14/3/11 They have been found and it seems to have been the slip of a keyboard. QP9-11 which relate to reviewing emergency admissions should have 47.5 rather than 27.5 points. That is a lot of points, nearly 5% of QOF - more than all of asthma.

What's On the Menu

NICE has published its menu of potential indicators. These indicators will then go to the negotiators for the decision of what goes into the QOF for 2011-12.

There is not a lot of "wow" here. There majority of changes reflect a tidying up of the current indicators with some made more explicit. There are no big ideas or even a unifying style to the indicators. Let's see what is ahead.

NM07: The percentage of patients with a history of myocardial infarction from 1 April 2011 currently treated with an ACE inhibitor (or ARB if ACE intolerant), aspirin or an alternative anti-platelet therapy, beta-blocker and statin (unless a contraindication or side effects are recorded)

A big wrap up here. CHD 9, 10 and 11 are combined with a requirement for a statin, regardless of cholesterol level. In fact CHD 7, the requirement to test cholesterol is also scheduled to go - the outcome measure remains. Actually this is just an assumption as the actual notes only suggest the replacement of CHD 11, but they must mean 9 and 10 as well, surely?

Personally I don't like these big indicators - they end up with horribly complex business rules, particularly when exception reporting comes in to play. Other than being awkward there is not much new here.

NM09: The percentage of patients with a new diagnosis of dementia from 1 April 2011 to have FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register

My least favourite form of indicator I'm afraid. Miss out in the first six months of diagnosis and you are stuck with that for ages. Depending where they put the threshold a slow start could affect results for years to come. Similarly success will result in several years payments. Much more sensible would be a new diagnosis within the year studied.

NM12: The percentage of patients with diabetes with a record of testing of foot sensation using a 10 g monofilament or vibration (using biothesiometer or calibrated tuning fork), within the preceding 15 months

A tidy up of the wording of DM 10. Nothing new.

NM13: The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) or 4) ulcerated foot within the preceding 15 months

DM 9 tidied with the risk classification added. Minor changes only.

NM15: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 15 months

I suspect that the wording here is misleading and they are not going to insist on the mentally ill having a couple of beers. They seem actually mean a record of the amount of alcohol consumed. This is the start of an extensive mental health section.

NM16: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months

There is little doubt that modern antipsychotics make you put on weight; indeed AstraZenica have just paid out on this. This is probably a large part of their potential to increase the risk of diabetes. I'm sure the guidance will explain what to do with the overweight in this group.

NM17: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 15 months

Currently MH9 is a general annual MOT for those on these registers. This includes a physical review. Most GPs do a blood pressure as part of this. This group of indicators replaceme MH9. Attentive readers may be wondering why NM07 combined various indicators and MH4 is being unbundled and whether there is any guiding strategy here. I know I am.

NM18: The percentage of patients aged 40 and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol: hdl ratio in the preceding 15 months

I expect some changes to this one in negotiations most likely to the use of total cholesterol rather than the ratio. Certainly our local lab advise HDL measurement sparingly and only once per person. Currently we have only recently agreed for the lab to do HDL measurement when the total cholesterol is low for QOF purposes in new hypertensives. Expect objections from chemical pathologists. This would be a closer monitoring of cholesterol, and particularly HDL than for patients with heart disease, strokes or diabetes. The associated documents don't comment on this.

NM19: The percentage of patients aged 40 and over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose level or HbA1c in the preceding 15 months

More checks on the mental health register. Worth doing for patients on antipsychotics but for patients with bipolar the evidence base is less clear.

NM20: The percentage of women aged 25-64 (in Scotland from 21 to 60) with schizophrenia, bipolar affective disorder and other psychoses who have a record of cervical screening within the last 5 years

NICE says they don't like double counting but these patients will also count for the main cervical screening indicators. There could be some quite small numbers here. The average number of patients on the mental health register is just over 48. If we assume roughly half are female and some of those are outside the age range then this indicator will apply to less than 20 patients per typical practice. Likely a lot fewer in some practices.

Percentage of patients on the Learning Disability register with Down's Syndrome aged 18 and over who have a record of blood TSH in the previous 15 months (excluding those who are on the thyroid disease register)

I certainly don't want to put down the importance of thyroid function to patients with Down's but I am left wondering how big the problem is at the population level. The economic analysis (which is fairly dire) suggests one in 1000 live births. Down's can be associated with heart problems and other issues which increase childhood mortality and even after that life expectancy, whilst rising, is still reduced. So lets say two thirds are over 18. That would be fewer than four patients in a typical practice and maybe one or even none at all for a small practice. Small numbers make bad indicators and is this really the best use of an indicator?

The percentage of patients with a new diagnosis of dementia from 1 April 2011 to have FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register.

Simple cheap tests. It is worth mentioning small numbers again. It would be worthwhile practices checking in January whether they have diagnosed someone with dementia in the previous year to get this indicator, if implented. If they have not then they would need to hunt someone out to get the points (tongue slightly in cheek, but only slightly).

The percentage of women with epilepsy under the age of 50 who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the previous 15 months

Probably small number here again. Quite how otherwise intelligent women will feel about being told the same thing annually will be seen. There is no lower age limit stated here but the lower limit for the epilsepy register is 18, which is probably too late to start. In reality this will likely become part of the annual review.

And now some more brief points

• The lowest level of HbA1c target for diabetes has been increased from 7% to 7.5% although these are no expressed in mmol/mol.
• The depression assessment indicator changes wording from "the outset of treatment" to "the time of diagnosis". In fact it always was the latter in the business rule. No real change.
• The second assessment moves from 5-12 weeks later to 4-12 weeks later. Probably a little easier
• For patients on lithium the creatinine and TSH must now be measured after the first of July rather than in the previous 15 months.
• For these patients the lithium must now be in the correct range after the First of December rather than July. All blood tests are still only required once a year though, just in more limited months. Unlikely to have the desired effects.
• Risk assessment for new hypertensives has the wording brought up to date with the current practice of only looking at those 30-74. This has been in the business rules for a while.
• CHD 2 is to have the date updated to next April and the emphisis changed from excercise tolerance testing to clinical assessment.

Removing Indicators

There have been a couple of new pieces of research in the last week or so relating to the QOF. I am trying to track down a copy of the this month's BJGP but fortunately there is free access to research in the BMJ and the paper The impact of removing financial incentives from clinical quality indicators. Lester et al.

The paper looks at the removal of incentive payments in California and, at the risk of spoiling the end for you, finds that there is a decrease in achievement when the incentives are withdrawn. In fact this decline is continuous over the years so things get worse. Comparisons are drawn with the UK and QOF although there are differences. In the US the payments rarely affect the clinicians directly but rather their employer. There were other programmes associated with the incentive payments that could have made a difference. Things not mentioned in the paper are that the incentives tend to be higher in the UK as a proportion of funding. Additionally most of the targets incentivised were fairly uncontroversial (cervical screening, diabetes control) whilst there is much more scepticism amongst clinicians about some of the QOF targets.

In general though the paper is a pretty easy read everyone except possibly for the NICE QOF advisory committee. Of course we won't really know what happens in the UK until it actually happens and has a chance to work through the system. As the earliest indicators will be removed is the 2011/12 year we won't really know until after the Olympics. Until then this is our best clue.

NICE New Indicators Consultation

NICE has a current consultation about possible new QOF indicators. It is open until the 11th of April (a week after Easter) and is certainly worth a look.

I won't go through the whole thing here, if you are interested you can read my submission. I will admit I am a little disappointed in the general scope of the indicators. Some of the current indicators are joined together and some are split apart. There is little feeling of an overall strategy or direction and even less of how indicators fit into the whole QOF. There is not really enough information to give a proper response. They are knee to know about potential unintended consequences but these tend to appear at the business rule level and there are not even draft versions of these. The document reads more as a list of intentions than indicators ready to be used. They don't even included suggestions of point scores which should be part of the economic evaluations.

I suppose this may get sorted at the negotiation level but we probably won't know that for another nine months. We will also find out how much the DH and GPC think of the QOF Advisory committee's work.

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.

Going out?

The QOF advisory committee also looked at indicators that might be removed. This makes sense as there is no point in suggesting new areas without trying to free up some cash to pay for them. You can read the full details in the minutes but I will give a summary here.

This was split into two areas. As nobody really knows what happens to service delivery when an indicator is removed they were classified as low risk and higher risk. The low risk areas were:

• CHD 5, Stroke 5 and DM 11 - The measurement of blood pressure in coronary heart disease, stroke/TIA and diabetes.
• DM 5 - The recording of HbA1c in diabetes
• DM 16 - The recording of cholesterol in diabetes

You may have spotted a theme here. These are all about the recording of measurements, or to use the NICE jargon, process indicators. They do not represent outcome. They all have matched outcome indicators. The outcome indicators are not quite a perfect match, of course. Outcome indicators have a much longer exception time after diagnosis or registration (9 months) than the process indicators (three months). They are also much more likely to be affected by other exception reasons such as patient preference for medications and patients having maximum tolerated therapy.

The QOF committee does not currently deal with either the points value of indicators or the thresholds, which is a pity. The effective indicator only works as a combination of criteria, thresholds and points and any division into parts is likely to miss some aspects of the whole. What we can say is that simple removal of these areas would represent a disinvestment in these areas. The degree varies by area. In diabetes the process indicators tend to be about a quarter of the value of the outcomes. The loss of these process indicators is in total about £5 per patient with diabetes. The figures for CHD and stroke are £4.30 and £2.64 respectively (these figures are for the whole register- the amount you gain or lose by performing a blood pressure on a patient already on the register, within the thresholds would be double these figures). To put it another way these indicators are worth £2,282 for an average practice in England.

It is possible to overstate the effects of these losses but there is now no incentive payment for measuring blood pressure in patients unlikely to hit the outcome targets - the patients most at risk.

The committee also suggest three indicators for removal which they state have a higher level of risk.

• DM 22 - eGFR or creatinine testing in patients with diabetes.
• MH 4 - Creatinine and TSH testing in patients on lithium
• Thyroid 2 - Checking TSH in patients on thyroxine - the committee also noted this would leave Thyroid 1 (the register) on its own with no other indicators. They did not actually write "so what would be the point?" but I'm sure I heard them in my head.

Diabetes would still require enough blood tests that the renal function box is virtually bound to be ticked at some point. It was, however, at least a nod to the importance of renal function in diabetes, especially in patients taking metformin.

I am no psychiatrist but lithium certainly seems to be yesterday's drug these days. Around 5% of practices have no patients at all taking lithium. I personally would drop all the lithium indicators.

There really does seem to be little point in keeping the thyroid register if the indicator goes. It is automatically generated. Could we see the first clinical area to be dropped from QOF since its introduction?

Next time - the possibility of changing the thresholds.

Coming in?

The QOF Advisory Committee at NICE has published the minutes of its first couple of meetings which took place in June and July. I must admit that I have quite high hopes of this committee. In fact I have to declare that I applied to sit on it myself although was not selected. The very fact that its minutes have been published is a sign of some improvement in the whole process. We can all see the indicators being proposed and developed. In this posting I will look at the new indicators that they have put on what they describe as the "menu".

On a really very busy day in June they looked at a lot of proposed indicators, and found most of them wanting. The majority were sent back for more work. This has had the unfortunate result of leaving their menu looking somewhat bare. Additionally the committee has not suggested the number of points or ranges that should be attached to each indicator. In fact there is so little detail that these seem more like a list of raw ingredients than fully prepared dishes. These proposed indicators will go on to the negotiators and may possibly become part of QOF.

First the good news. A proposal for staged indicators for blood pressure in diabetes at 150/90 and 140/80. It has long been a perverse part of the QOF that it was much more lucrative to deal with mild disease than more significant disease and this would both reward tighter control and extend the reach of the QOF. Much will depend on the points awarded to each area - no details are given.

Much lower on the practicality scale is the suggested annual thyroid blood tests for patients with Down's syndrome who are over 18. The clinical and financial case for this in the briefing papers is somewhat thin at best. Even worse is the practicality of this indicator. A rough calculation (based on a birth prevalence of 1 in 1000 and a life expectancy of 50) suggests that a typical practice would have around three patients to check annually. Small practices would have fewer and, as we are dealing with such small numbers, many are likely to have none at all. These practices would not be eligible for the points at all in a similar way to that seen already with the lithium indicators. In 2007-8 579 practices (out of ten thousand or so) gained no points for these as they had no patients taking lithium.

The final indicator on the menu proposes the mentioning of contraception and conception advice to women of reproductive age currently treated for epilepsy. It seems to assume that they are quite forgetful and suggests they should be reminded annually. It is difficult to argue that this is a bad thing to do but there is little evidence for any positive effect either. Even the economic experts say that there is so little evidence that assessment is impossible.

It is a rather disappointing menu with little that is new and exciting and little that seems likely to be of significant clinical benefit. The committee sent many other potential indicators back as "must do better" and we wait to see if they can. Next time - what might be going out.

What to do now - part two

Back in January the I posted the first What To do Now article. Basically a reminder of which new QOF indictors "went live" back then. If you have not read that then I would suggest giving it a look before coming back here.

I did miss one thing off the January post which was the requirement for everyone on the CKD register to have either an albumin:creatinine or protein:creatinine ratio recorded in the notes. Actually the protein:creatinine ratio is not officially recommended but it is all that some laboratories will do and will still count for the QOF.

What is new is a second assessment of the severity of depression - 5 to 12 weeks after the first one. Despite evidence that these assessments are of minimal use at best there will be twice as many of these this year. The timing here is quite crucial and will make a lot of difference to how it will work in practice. To put it simply following a diagnosis of depression you will have 28 days to code the first assessment. From the time of the first assessment you will have to complete the second between five and twelve weeks after that. Why is this significant? Well any patients who have their first assessment after 7th January 2010 and then miss their second will not be counted. If they do have their second but had their first before 25th February 2010 they will be counted. After that they never will be counted. There is a short window of potential catch up time in the new year. For this year you will need to start on the second assessments from the 7th of May (for those patients with their first assessment on the first of April just gone).

Finally there are two primary prevention indicators. PP1 is simply the calculation of a Framingham risk score (or ASSIGN score for readers in Scotland) for all patients diagnosed with hypertension since April the first who have not had CHD, Diabetes or stroke in the past. Patients already on statins or similar will also not be expected to have a score although this may need an exception code. You have three months before (?) or after the date of diagnosis to do this.

PP2 asks that all patients who have been diagnosed with hypertension since the start of April have advice about diet, exercise, smoking and drinking sometime this year. There are already separate codes for each and these may be used for the rules although how they deal with non smokers and tee totallers remains to be seen. Templates would be useful here and if you have any I would be delighted to publish them to a wider audience.

You can find the full rules and regulations at the BMA site, although I'm not sure for how long as they tend to shuffle their links without warning.

Good Luck!

QOF indicators review consultation

Monday is the last day for responses to the Department of Health consultation on changes to the process of review of indicators in the QOF.

I have sent in my own response to the consultation. It is proposed to move the development of indicators across to NICE although there is no terribly good reason given why this should be done. In any case their economic model is just a bit muddled - a pity as this is the major new innovation in the process. We await the results!

Changes to QOF - details available

The BMA has moved faster than I have ever seen in getting details of the new QOF indicators out. After a rather vague press release this morning this afternoon produced a letter from Lawrence Buckman with a link to the details of the QOF changes.

It is only three pages and well worth a read. Highlights include the addition of a requirement for albumin:creatinine ratio in all patients on the chronic kidney disease register. This may raise a few eyebrows in biochemistry labs around the country who may not know what is going to hit them. (If they want to know what is going to hit them then a quick browse around the CKD register on the site may be useful. Around 1.8 million urine samples are headed their way.)

The current contraception indicators have gone and are replace by 8 points - six of which are for plugging coils and implants. It will be interesting to see the evidence base for this one. This will be at least a small crumb of comfort to university practices likely to be hit hard by the loss of the square root formula.

There is a bit about primary prevention in those newly diagnosed with hypertension - which should be a manageable number. In essence this boils down to finding out if they smoke, eat badly, drink alcohol and take no exercise and telling them not to do these things. I am really trying not to be cynical but very few patients are under any illusions about any of these things and it always seems a little lame.

There is a tidy up in diabetes with three thresholds including a tough 7% HbA1c (again evidence will be interesting to see). Inhaler technique is out and the MRC assessment - which is purely function is in. Actually quite a usable scale and much easier than finding an inhaler and watching them use it.

Finally depression. There is a new indicator for the reassessment of depression severity after 5-12 weeks using PHQ-9 or whatever. The patients aren't free of the questionnaires yet!

The last word has to go to Laurence Buckman - chair of the General Practitioners Committee and now Youtube star.

QOF changes 2009 onwards

Results of negotiations on next year's contract have been released last night. There is quite a bit of information although the final details are not absolutely clear.

First off there is a bit about money. There is agreement on how uplift for 2009/10 will be allocated. This may prove to be a bit academic in the current climate as it is not entirely clear whether there will be any extra cash on the table. This will be up to the DDRB. The cash will be divided up with 37% going to the Global Sum - 11% to the correction factor (to maintain MPIG) - 26% to QOF and 26% to Enhanced Services.

The effect of the above is likely to allow the Global Sum and MPIG to rise roughly together but a larger percentage increase in QOF and even large in Enhanced Services. Thus QOF is going to be a more significant income source to practices than it was before.

So what of the QOF itself? Well the big thing to go is the survey. The Department of Health has decided to do its own, by post. This is probably a relief to practices, to whom the administration was a hassle, and to those patients who feel bombarded by surveys. It may be a bit of a kick in the teeth for the nice people at GPAQ but there is of course nothing to stop people from continuing to pass them out anyway.

This will free 55 points from PE 2 and PE 6. There are also another 17 points being shaved off other (undisclosed) indicators. There is probably an interesting bit of work to show the effects of shaving points on overall achievement in those areas. These 72 points are going into new clinical indicators for which we have some vague suggestions. Official(ish) bits in bold.

• Helping to prevent the development of cardiovascular disease in people diagnosed with high blood pressure (13 pts) - other than controlling their blood pressure I assume. Possibly cholesterol measurement but this does not seem enough points for this - just measuring BP currently gets 20 points.
• Advice on long term contraception(10 pts) - for whom? Is this to combat teenage pregnancy. Long term contraception tends to be used in the over 30s - aiming to change this?
• A new indicator for depression to reduce early cessation of treatment (20 pts) - no idea how this might work.
• Beta blockers for heart failure (9 pts) - which is one of this year's new DESs
• Improvements to the indicators for chronic kidney disease (11 pts), diabetes (7pts) and chronic lung disease (2pts) - or at the very least changes.

In addition the square root formula has gone from next year, and with the uplift for those practices with less than 5% of the maximum prevalence will go in 2010/11. These changes turn things into a much simpler item of service payment once over the 40% threshold.

Developments awaited.

Updated 12:45 with points data and square root stuff.

New Business Rules (v12) for 2008/9

We are now about a third of the way through the QOF year and I have just come back from my holidays to find that the new version of the QOF business rules has arrived. It is a no more gripping read than it was before and fortunately the changes are fairly minor this year. Most of the obvious changes seem to be in the area of smoking - both the clinical area and Records 22. This is the area that has received most attention this year - at least in terms of the coding areas. Just a reminder of what the guidance says:

The guidance has also been updated and in particular we would draw your attention to amendment to non-smokers and ex-smokers. Non-smokers should be recorded as such up until the age of 25 while the smoking status of ex-smokers should be for 3 years and only thereafter if their smoking status changes.

Now this has been implemented almost exactly as you see it here (for the one problem see below). Arguably there is a degree of ambiguity, and a missing bracket, in the way that the rule about three years is written but I am sure that the system suppliers can be relied on to implement it sanely. There is, however, an interesting anomaly in the way that the text above specifies the criteria. If a young man were never to have smoked by the age of 24 this would still have to be coded on an annual basis. If, however he had smoked when he was 15 and then became an ex smoker this would only have to be recorded from the ages of 18 - 20 and can then be stopped. Ex-teenage smokers are thus less work than those who have never smoked.

There are not that many young people in the smoking clinical indicators - they just don't feature in the chronic diseases that much with the possible exception of asthma and for asthmatics the smoking indicator only starts at age 20 (there is another indicator for younger asthmatics at Asthma 3). However around 80% of the practice population is also covered in Records 22, including all of the 18-25 year olds. For a typical practice this represents about 4742 patients. There are only 11 points here, around £1370 equivalent to just 58 pence for each patient in the "scoring zone" from 40-90%. It is likely that annually chasing young people who don't often attend the surgery to check that they have not started smoking will simply be uneconomic. That is not to say that nobody will do it though. For 2006/7 practices achieved 82% overall.

The recording of ex smokers for three years is however rather fragile. This may cause problems in the future although the effect should be limited this year. The problem is that the rules look only at the most recent codes and this could trip practices up. If a patient had given up smoking you could record this in years one, two and three. They would then not need a record again - ever. However if you recorded in years one, two and three - missed year four and then recorded again in year five another code would be needed in year six. The rules would see the code in year five and missed the previous year and not the three codes in the years before.

Now this is not really the fault of the rules writers. The structure of the rules is not that flexible and they have done their best within these limits. The rules have a very linear structure and there is no option for looping or iteration. The designers of QOF at the DH and the BMA are getting more ambitious with much more complex targets; the smoking rules are probably the most complex in the whole of the framework so far. Many people have big plans for new QOF areas in the future and it may be time to look at an overhaul of the way the rules are set and the systems that implement them. We are likely to see an increasing number of problems of this nature unless ambitions are reigned in a bit - and personally I don't see that happening.

QOF changes

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.

QOF changes for 2008/9

The BMA has released details of the changes to QOF targets for the year 2008-9. Actually this is more a summary of where the changes are as the detailed guidance is not yet out, and it is in the detail that the interesting details are located.

The headline is probably the removal of fifty eight and a half points largely from the organisational domain but five points have also been take from the COPD spirometry measurement section. The spirometry has also been made more explicit in asking for post bronchodilator spirometry.

There are some other minor changes. They are worth knowing early because they may be difficult to catch up with later in the year. There is now a requirement to refer all patients with stroke or TIA within one month of diagnosis. Along with the spirometry changes this will apply to new diagnoses from the first of April 2008. The reference date for ECG investigation in atrial fibrillation has also been moved to the same date.

One of the changes with widest effect may be the changes to the smoking area - particularly as it affects around one in five patients. As it stands this refers only to the clinical area on smoking which refers to those with diabetes, cardiovascular and lung disease. Patients with psychotic and bipolar disease have now been added to this area (probably a drop in the ocean) and the criteria have changed. Currently if a person had never smoked then you didn't have to ask them again. If they had ever smoked they needed to be asked annually. Now all patients under 27 need to be asked annually and you can stop asking those 27 and over who have never smoked or have not smoked for over three years. My sympathies go to whoever has to write the business rules for that one.

In practical terms this is likely to mean fewer patients needing coding over the course of the year as there are few patients under 27 years old on the chronic disease registers. The BMA guidance seems to suggest that there is to be no change to the organisational smoking indicators which apply to the whole of the practice population over 15 years old. As it stands it would appear that the old rules (if they have ever smoked then you need to ask annually) still apply to RECORDS 22. This would seem to be an odd situation, but I am sure that they have spotted it already!

Finally prevalence day is being moved to March 31st from next year which makes a lot more sense. It takes seconds to do the calculation on a computer and allowing six weeks turned out to be overkill.

Update 1st April

A Department of Health letter landed on my desk today confirming that the smoking rules apply to both the clinical and organisational sections.

Questions in the House

Perhaps an old fashioned phrase to describe a significant event but there have been questions in Parliament about the QOF. At health questions this week the Alan Johnson defended of putting cash into extended hours rather than clinical areas. He accused the BMA of propaganda in suggesting the reverse. That suggestion seems to have produced a sharp intake of breath from the Honorouable Members. Ultimately though, like most parliamentary answers, there is more heat than light here.

Who loses what?

As many of you are probably aware the site has had information about the potential loss of cash to practices under the government's proposed imposed changes to the QOF in England. If you have not seen this you can click on the link on the left of each of the practice pages. There is also table of the changes effects at PCT level.

Of course now that we have these statistics we can look at the breakdown a little. As I have said before the threshold changes will mostly affect those who have had most problems in meeting the targets. The practices that have tended to have lower score have tended to be those in more deprived areas. A reasonable hypothesis would be that more deprived practices tend to loose out more.

We can go onto test this. Helpfully the deprivation index for most practices was published as part of last year's GP patient survey. We can put all of this together in a spreadsheet and work out the loss per patient for the threshold changes and overall for whole set of changes. Not difficult as we have practice list size from the QOF data as well.

As it turns out there is a correlation between the deprivation and the cash lost through threshold changes at practice level. For the mathematically minded the correlation is 0.13 - not particularly strong but it is there. In practical terms the thousand least deprived practices are to loose 62 pence per patient whilst the thousand most deprived practice will loose 84 pence per patient - a difference of 12 pence. For a "typical" practice of 5891 patient this works out at £1,287 per year between the most and least deprived practices.

This all looks pretty bleak but there is another factor that works against this effect. The removed points take more from practices that have gained all of these points in the past. Statistically these tended to be practices in the least deprived areas. If we bring in the removed points then the effect almost disappears. The correlation drops to 0.03 which is small enough to be ignored.

So balance is restored - whether by luck or judgement! It does however give some idea of the less obvious effects of changes to QOF.