30th January 2009
Primary Medical Care
Leeds LS2 7UE
Thank you for the opportunity to comment on the proposals for the
development of the Quality and Outcomes Framework.
I am a full time general practitioner and the lead for the Quality and
Outcomes Framework within the practice. I also run the QOF Database website
http://www.gpcontract.co.uk where practice level QOF data is published.I
have modeled some changes to QOF to assess their impact before
implementation and published the results on the website. I am in the final
part of an MSc in Healthcare Informatics and recently submitted my
dissertation looking at statistical patterns within QOF data.
Q1: Do you agree with the proposed aims of the new process? If not are there any
other important aspects that should be considered?
The principles of the aims seem to be solid. It is not entirely clear how
the process will differ significantly from the current one and what the
advantages of the new process are likely to be. Quite simply the case for change
is not made and in particular how these aims are not provided, or cannot easily
be provided by the current system.
There is, also, little mention of the timeliness of the indicators. Some areas
of the QOF have been discredited in the past due to being based on evidence that
has been widely considered to be out of date. If there is not a reasonably swift
process for assessment of indicators then there may be a significant lag between
evidence and the QOF.
Q2: Do you consider that the new process will help to address health
inequalities? What do you consider that the impact on equality is likely to be?
There is some evidence that the current QOF has reduced health inequalities
in some areas. The process above would seem unlikely to have significant effect
on health inequalities in itself but future indicators may have some effect
depending on the choices made.
Q3: Do you agree that the scope of the new process should cover clinical and
health improvement indicators in the QOF, excluding indicators relating to
vaccination? This scope would cover indicators in the Clinical Domain of the QOF
(apart from CHD 12, STROKE 10, DM 18, COPD 8), indicators in the Additional
Services Domain and the following indicators in the QOF Organisational Domain:
Records 11, 17 and 23.
It would seem curious to limit the process in the way listed above. As the
process is to be based on NICE guidelines it would seem not unreasonable to add
the guidlines of the joint committee on vaccinations into the same process. This
would, of course, depend on how integrated the QOF is into the rest of NICE
process or whether it is seen to stand alone. In the latter case it should be
easy to integrate immunisation indicators.
Two separate processes are likely to lead to inconsistency between indicators.
Q4: Do you agree with the proposed key elements of the new process and the
proposed content of NICE advice?
The basic process is sound. There are quite a large number of bodies
involved (NICE, NHS Employers, GPC, an external contractor and the Information
Centre) which likely to make the process rather slower than it might be.
The process described in Annex A is described as taking two years from inception
to placing in the SFE. However it would be a year after that until the data was
collected under the QOF arrangements. As the process is based on NICE guidelines
it is likely to be a couple of years from the availability of evidence before
the start of the process of evaluating indicators. There could easily be a delay
of five years between evidence and measurement which is unlikely to be of
maximum benefit to patients.
The development of business rules is of course a significant part in making sure
that the recommendations will be able to be implemented. As we are faced with
the current problems where smoking indicators have proved impossible to
accurately specify using business rules this is a welcome development. However
there are more subtle issues with regard to implementation that go beyond the
purely technical. Examples in the current QOF include depression assessment
questionnaires which tend to be used face to face rather than after of the
consultation where the evidence suggests that they should be used. This was an
entirely predictable consequence of the rules which unfortunately was not
spotted at the development stage. Review by front line GPs with experience of
interpreting rules is required to ensure indicators can be implemented
Q5: Do you agree with the proposed approach to reviewing existing indicators?
There are significant problems with the approach which based on flawed
assumptions which pervade much of the proposals. The only criteria for removal
on an indicator is given as "they have been sufficiently embedded in practice
that they should not require continued incentivisation and are recommended to be
There is no evidence that there is inertia in UK general practice, indeed the
evidence of the introduction of QOF is quite the opposite. General practice
treatment adapts rapidly to incentives. Whilst there is little academic evidence
on the effect of withdrawal of indicators it would seem naive to believe that
activity would continue at previously levels. For the majority of practices QOF
is such a significant source of funding to the practice that its indicators are
the top priority. Indicators removed are likely to slip down the priority
Secondly there is no outcome to this process which suggests that there is no
longer good evidence for this indicator and that it should be removed as no
longer clinically relevant. An additional outcome is required for this
Q6: Do you agree with the proposal to retain the principles for QOF
indicators in the General Medical Services Statement of Financial Entitlements
set out in Annex C?
Yes. The credibility of the assessment of these indicators however is based
on the clear independence of NICE from government influence. As NICE is funded
and its reviews can be directed by government it will have to work hard to prove
its independence as it moves into new and more political areas.
Q7: Do you agree with the draft criteria for prioritising new areas for
indicator development attached at Annex D or do you have changes to suggest?
Prioritisation based solely on areas which NICE happens to have reviewed
already could be a significant limitation of the possible areas for
Q8: Do you agree with the principles proposed for assessing the cost
effectiveness of QOF indicators? If not what changes would you suggest?
Unfortunately the proposals in this area seem to be rather muddled and
display a poor understanding of the operation of general practice under the
General Medical Services contract. It does not consider adequately the various
views of cost effectiveness that are likely to affect a given indicator. For an
indicator to be effectively implemented the indicator must be cost effective for
the NHS, practices and even patients, although I do not propose to discuss the
patient calculation in this document.
I will first deal with the suggestion in paragraph 40 that the QOF payment is
not regarded as linked to the specific cost of the intervention. Where an
intervention is new or has not been performed it is disingenuous to suggest that
it is already covered by existing funding. It is also bizarre to suggest that an
indicator where the reward is less than the marginal cost to a practice is
likely to act as any significant form of incentive.
The formula given in annex D is again highly simplistic as it deals with the
health service as a whole rather than the specifics of general practice funding.
In fact it flat contradicts the statements made in paragraph 40. The delivery
cost should not include the cost in time and equipment to the practice as this
is (fully or partially) covered by the QOF payment. The formula given will
therefore tend to underestimate the cost effectiveness of indicators due to a
degree of double counting.
There will still be some NHS cost for drugs prescribed, laboratory
investigations and referral and these must be considered.
The measurement of cost effectiveness and its translation into effective
incentives in specific contractual contexts is thus a lot more complex than the
few paragraphs in the consultation document suggest and I would suggest should
the subject of a consultation of their own. There is quite a lot of overlap
between this area and the areas discussed in question five - both seem to assume
that additional work will be absorbed in to general practice with additional
resources. This seems unlikely to be borne out in reality.
The process must, however, be seen to be transparent.
Q9: Do you agree with the proposals for the scope of the advice that NICE
would publish to inform subsequent decisions on choice of indicators, thresholds
Q10: Do you agree with the proposals for the frequency of QOF reviews and the
estimated output in terms of existing indicators reviewed and new indicators
developed for the national menu?
The current system has delivered, very roughly, significant changes to QOF
every two years with a few "tweaks" being made annually. The pace proposed would
seem very rapid and reduce the stability of the QOF. Patients appreciate a
consistent and predictable system and changes on an annual basis can increase
the feeling of medical control rather than patient control.
Rapid changes are also likely to reduce practices desire to set up robust
systems rather than a temporary "quick fix" when it is suspected that an
indicator is unlikely to last. It is likely to reduce capital expenditure and
staff training where there is no predictable payback period.
Q11: Do you agree with the proposals for transition to the new
As a system it seems satisfactory although the case for transfer in the first
place has not really been made.
Q12: What are your views on the idea of reserving a proportion of nationally
agreed QOF investment to enable PCTs and GP practices to agree local indicators
selected from a national menu of approved indicators? Do you have any
other suggestions for developing local QOFs or comparable local incentive
Local indicators will mean variation in indicators, incentives and
consequently services in different parts of the country. This will be a postcode
QOF. National comparators will also disappear. This is not a desirable direction
There are already local enhanced services in many parts of the country which
largely fulfill most of the functions which would be expected of a local QOF.
These proposals would simply add additional complexity and difficulty to review
and implementation without clear benefit.
Q13: Do you have any views on the balance between the proportion of QOF that
should be determined nationally and the proportion that could be left for local
This should be minimal to minimise adverse effects.
Q14: Do you have comments on the type and degree of national IM&T support
that PCTs would need for extraction of data, analysis of achievement and
payments to implement local QOFs or comparable local incentive schemes?
Despite what I have stated above the IM&T support is likely to be relatively
easy to implement once the indicators have been considered, negotiated and the
business rules generated at national level. Practices systems could look at all
national indicators or each indicator activated or deactivated locally by
practices.. Turning indicators on and off for payment in QMAS and its
equivalents for each practice is unlikely to be a major technical challenge.
There is likely to be a significant challenge if indicators are not specified
nationally including business rules. Local generation of indicators is to be
avoided. It would be a mistake to have any of these rely on new extraction
technology - an area that does not have a terribly good track record.
Dr Gavin Jamie BM