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.
Starting Snomed
Overextended?
The changes to the QOF detailed on this blog and the detailed calculations of losses under the proposed contract imposition are only a relatively small part of the current issues between GPs and the government. The central issue from Numbers 10's point of view appears to be extended hours. If the governments proposals are accepted then a Directed Enhanced Service will be commissioned for these extended hours. The politics are complex an I would direct the interested reader to Lawrence Buckman's letter to the profession.
The fundamental drive of the DES is that there should be 30 minutes of extra time per one thousand patients on the list to be delivered in 90 blocks in the evening or weekends or 60 minutes in the mornings. We are, however on shifting sands here. A new provision brought in at the end of January is that there should be no time when reception is closed during the core hours. Any reception close would have to be replaced with clinical time. The extended hours would be agreed with the PCT and based on the results of the GP Patient Survey, a national survey of patients about primary care.
The results of the patient survey have been published and so the figures can be used to work out an estimate of the impact of the DES. What I have done on this site is to calculate the amount of time required from each practice and then allocate those hours according to the result of the survey. Thus is 51% wanted weekend access and 49% evenings and there were two sessions to allocate then there would be one to each. If there was only one it would go to the weekend. A fairly simple formula but it does make it easy to automate. The ultimate detail is in the source code.
The results can be seen on the practice pages. The summary is that it is not the couple of hours a week that many imagined. 55% of practices will be required to produce three hours or over on a Saturday. Around 160 practices would also be doing Sundays under this formula. Interestingly only eight practices would be required to provide early morning surgeries.
Some of the problems with the current proposals are also seen. It is widely reported that simultaneous surgeries would not be permitted (i.e. you could not supply three hours of time by two GPs working for 90 minutes simultaneously). One of the effects of this rule is that opening hours for smaller practices will be considerably less than those for larger practices. Under this rule two practices would be open from 8am on Saturday until half past midnight on Sunday morning. Clearly this is absurd.
I will try to keep the model updated with changes, but there remains a lack of detail in these proposals, and much of the detail that does exist may not be that practical. Obviously if anyone from the government side of negotiations knows better then the email address is below!
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.
Less cash for QOF says HMG
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.
Welsh data now online
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.
What's the point?
A little nihilistic maybe as questions go but when applied to
Well there is, as yet, very little evidence of actual improvements in patients outcomes and at least some evidence of very little improvement. It is simply too early to say for sure. An article in this weeks BMJ (subscription required outside of NHS) goes rather further and suggests that harm may actually coming about because of the targets.
The quality and outcomes framework diminishes the responsibility of doctors to think, to the potential detriment of patients, and encourages a focus on points scored, threshold met, and income generated.
Pretty severe stuff but it is a feeling anecdotally shared by a reasonable number of GPs and indeed some patients (not suitable for those offended by swearing). Indeed there are quite a number of points made that I would broadly agree with. There are weaknesses in the approach of QOF, in particular in the application of treatment to groups rather than individual circumstance, although that is a problem Evidence Based Medicine has been struggling with for years - although to describe the QOF as fully evidence based is to rather push the definition.
This debate has some time to run.
Exception reporting in England - all new!
In all of the general excitement(!) of the release of the 2006/7 QOF data it would be quite easy to miss the QOF exception bulletin produced by the Information Centre for England for the same year. Not perhaps the most gripping of documents but very useful none the less. It is rather dry with plenty of statistics but relatively little comment and no exploration of the reasons behind individual indicators. If you are not familiar with exception reporting in QOF it may be worth looking back at past exception articles.
I am not going to repeat any of the data there, rather to try to provide a little background to help understand what is going on. Page 11 (and to their credit the page numbered 11 is also the 11th page of the PDF - certainly not universal) shows a table of the top ten excepted indicators. There is also the bottom ten but I will concentrate, as I imagine most people will, on the highest figures.
Top of the list is CKD 3 (CKD and hypertension with BP less than 140/85) which has an exception rate of nearly 30%. The equivalent indicator for hypertension alone (BP5) does not even reach the top ten. What is going on here? Well firstly hypertension is very difficult to control in kidney disease so maximum tolerated can quite easily be reached. There is, however, a bigger and more technical issue. Following diagnosis of a condition a patient is automatically excepted for the next nine months if they don't meet the target. This was a new indicator this year and was not really a commonly made diagnosis before. With a simple assumption that practices started work on this QOF a year before (April 2006) then three quarters of the patients could have been excepted if they did not hit the target ( 9/12 ). Suddenly 30% seems fairly good. We can expect to see this drop next year.
Next is CHD 10 (beta blockers in CHD) which has always had a high exception reporting component. Rises a bit this year may be due to the advice that beta blockers are not much use after a year following a heart attack. They are also used much less first line for hypertension than previous due to new research. QOF is looking a bit dated here. Expect a rise again next year.
At third is AF 02 (ECG to diagnose atrial fibrillation) at 21%. Once again this indicator is for quite a short period - looking back over a year. Thus in this case 25% could be excepted automatically. Still fairly high though.
The timescale issue is also true of Asthma 8 (reversibility) at 20%, Stroke 11 (referred for investigation) at 18% and Dep 2 (depression scoring) at 17%. Again these only apply since first of April 2006.
MH 6 (comprehensive care plan) actually seems quite low at 17% due to the mental health register containing everyone who has ever had a psychosis or bipolar disorder - whether they still have the condition or not. MH 9 (annual review) is much the same at 15%.
Finally in the top ten is Epilepsy 8 (fit free for a year) at 17%. This reflects the difficulty in controlling some forms of epilepsy combined with a general lack of problem seen by some patients with occasional fits.
What is interesting is that only Epilepsy and beta blocker indicators have some clinical relevance in the exception reporting. All of the others (eight out of ten) say more about the business rules and the administrative nature of the indicator rather than patients or practices. So the take home message has to be don't place too much importance on exception reporting rates.
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