The Practice

30th January 2009
Quality Team
Primary Medical Care
Room 2E56
Quarry House,
Quarry Hill
Leeds LS2 7UE

Dear Sir/Madam

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 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areas of the QOF have been discredited in the past due to being based on evidence that has been widely considered to be out of date.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 influenza
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 effectively.

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 retired."
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 significantly.

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 situation.

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 consideration.

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 and
payment levels?


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 system?

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 schemes?

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 to take.
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 calculation of
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