Peering into the minutiae of QOF changes for this year, resident QOF expert Dr Gavin Jamie explains exactly how practices will be affected
The changes to the contract for 2014/15 were announced as early in the year as they ever have been - a full five months before their implementation. Negotiations seemed only to take a few weeks and both sides came away claiming success in getting the changes that they wanted.
The biggest headline was the cut to the quality and outcomes framework (QOF). A total of 341 points were removed representing around 40% of the points available this year. There are no new indicators and none of the prospective indicators in NICE’s QOF “menu” will be implemented in the next year. Most points lost were from clinical indicators and the cash from these has been transferred into the global sum.
Of course, these two things are calculated differently and so, while the overall cost across England will remain the same, practices could see some individual difference in the amount of money that they get. QOF is calculated using relative disease prevalences and the global sum is calculated using the Carr-Hill formula which uses a much wider range of factors - largely the age and sex of the practice population. Practices with high prevalence but a relatively young population may see losses, and practices with the opposite profile are likely to gain financially.
The difficulties for GPs are likely to be in the details. Changes to QOF seldom have been accused of having great strategic vision and there is little difference this time around. Indicators seem to have removed without a great deal of regard where they fit into the bigger picture.
Epilepsy, for example, has been left with only a register and no indicators requiring any action by practices. As there is only a single point for the register it is not certain what is to be achieved by its retention.
Hypothyroidism has become the first clinical area to be entirely removed from QOF and this gives a clear indication of why the cash has been diverted into the global sum. Practices will continue to treat thyroid disease as they have done since before the QOF was ever thought of. The resources to continue will remain. All that is actually removed is the bureaucracy around coding for the indicators.
Although there has been some debate about how much QOF has improved clinical care, there is unanimous agreement that it has improved coding in the areas covered.
A new code for many this year was the biopsychosocial assessment. This was pretty much what most doctors would recognise as a good history and mental state examination. This will no longer be required to be specifically coded next year. The review remains, although the timescale has changed to two-eight weeks. Currently the time is between 10 and 35 days and fits fairly easily with a two week follow up. This is likely to be more difficult next year and the review is more likely to occur around the four week mark.
Lots of similar indicators have been removed. The cholesterol outcome indicators for patients with stroke, coronary heart disease and peripheral arterial disease have been removed. Once again it is expected that practices will continue to check cholesterol levels, with the remuneration in the global sum. The only cholesterol indicators left in the QOF are for reaching 5mmol/L in patients with diabetes and recording a cholesterol:HDL ratio in patients who are on the mental health register.
There are some indicators for which it is less likely that practices will continue to enter the codes in the same way. The GPPAQ questionnaire which clumsily attempted to quantify the amount of exercise taken by patients with hypertension has been removed. The follow up indicator for giving exercise advice to patients who were less than optimally active has also been retired. These were generally thought to be pretty unhelpful although the principle of encouraging exercise remains a valid one. The failure was in the structure of the indicators rather than in the promotion of exercise.
Similarly the rather over-complicated indicator concerning dietary review in patients with diabetes has also been removed.
Other indicators that have felt intrusive have been removed, including the annual lifestyle advice in patients who have been diagnosed relatively recently with hypertension. There will also be no need to code annually that long acting contraceptive advice has been offered to women taking the contraceptive pill. The requirement to offer this advice to women who receive emergency contraception from the practice remains unchanged.
Despite these being removed from the QOF, NHS England has suggested in a letter to CCGs that it intends to continue to monitor the indicators that have been retired. Effectively practices will continue to be judged by these criteria although there will be no direct payment for achieving them.
This may be more significant in some cases where previously indicators came in two parts and only the first part was withdrawn. The QOF Indicator Development Committee of NICE noted that it would be relatively easy for practices to game these indicators in the renewed framework.
In the area of Atrial Fibrillation, for instance, the indicator requiring the calculation of a CHADS2 score have been removed but the two further indicators for acting upon the scores remain in the QOF.
The denominator for these “action” indicators (the action here is the prescription of an anticoagulant) is those patients with a particular risk score. If the practice only calculates the score in a small number of patients then this denominator, the number of patients requiring a prescription, will also be small. With a smaller number of patients the indicator will be easier to achieve.
The same is true of the measurement and treatment of microalbuminuria with an ACE inhibitor in patients with diabetes. The indicator for measuring the albumin:creatinine ratio in diabetic patients has been removed but the further indicator for prescribing an ACE inhibitor or angiotensin antagonist where the ratio is raised remains.
In the Public Health domain there will no longer be an indicator for recording smoking status in all adult patients but there will still be points for giving smoking cessation advice where a patient is recorded as a smoker.
It is likely that NHS England and its local teams will look most closely at these and similar indicators even after they no longer have any points assigned to them.
Despite there being no new indicators there are a several changes to the existing indicators although these are relatively minor and generally make life a little easier for practices.
The time in which a review must occur after a diagnosis of cancer was reduced from six months to three month in the 2013/14 QOF year. It will return to six months from April 2014.
More significant are the changes to the hypertension area. This previously contained the QOF indicator with the largest number of points - fifty for achieving a blood pressure target of 140/90 in eighty percent of patients under eighty years old. This had been split from the older target of 150/90 which persisted for patients of any age with ten points.
The large number of points was justified as there were a very large number of patients involved - almost one in seven patients on practice lists has a diagnosis of hypertension.
The points are cut quite dramatically with the lower blood pressure indicator disappearing along with most of its points. Ten points move to the higher threshold indicator but there is still an overall drop for hypertension targets of two thirds from sixty to twenty points. These are now spread pretty thinly over the large number of patients on the register. The indicators now looks back over a full twelve months rather than the previous nine. In practical terms this removes the odd effect when blood pressure readings in April, May and June did not count towards the QOF hypertension area.
There is a relatively small change to the indicator requiring a CT or MRI scan following the diagnosis of stroke. Previously all patients who had their first stroke since April 2008 needed to have had referral to a stroke clinic or other investigation. This will be changed so that only new diagnoses since the previous April will be included. Whilst only one referral will be needed in patients with TIAs each stroke will need a new referral. This will make things simpler for practices as patients with old stroke will drop off the indicator and practices will be less dependant on the actions of other surgeries when new patients join them although the business rules are bound to throw up some anomalies. It will however be essential that a new diagnosis is made in at least one patient during the year to make it possible to achieve the two points that this indicator carries.
Although the organisational domain was removed in 2013/14 there were a number of indicators that still looked very much like them. The boxes that needed ticking to confirm that the practice had a system of informing women of their smear results, providing antenatal care and providing child health services have all been removed.
There were still thirty three points for providing appointments of no less than ten minutes. This has also been removed with the intention of allowing practices to be more flexible and provide appointments appropriate to individual patient needs.
All of the points released by the indicators mentioned so far will be put straight back into the global sum. An exception to this pattern is the cash for three points available after the removal of the requirement to measure TSH annually in patients with Down’s Syndrome. This will be transferred to the current Learning Disabilities Direct Enhanced Service (DES) which will, in turn, be expanded to include patients from fourteen years old and it will also require an annual health action plan.
The biggest chunk of points will come from the abolition of the Quality and Productivity indicators. There are one hundred points here and it would be hard to find many people who felt that they were usefully spent. Very often they involved looking at inadequate and incomprehensible statistics, sitting through dull meetings and producing actions just for the sake of doing something.
However before you completely relax it is worth considering what will be replacing these indicators. The money will be used, along with money released from the 2013/14 risk stratification DES to introduce a new admission avoidance DES. This looks to be every bit as onerous as the QP indicators although it is to be hoped that there will be more benefit to patients. The details will be important and practices will need to look closely before they decide if they want to proceed.
While there have been considerable cuts to the QOF this should be relatively cash neutral for practices. There will be a reduction in “bean counting” and the QOF should require less administration from practices next year but this difference is likely to feel fairly small. The overall effect on workload, particularly in direct patient contact is likely to be minimal. After the previous year’s imposition which felt frankly malicious, this agreement comes as a welcome relief.