Towards world class healthcare for all

Transcription

1 Towards world class healthcare for all

2 Quality and Outcomes Framework Plus Copyright NHS Hammersmith and Fulham Copyright ehealth Unit, Department of Primary Care and Social Medicine, Imperial College 2008 Published by NHS Hammersmith and Fulham. This publication may be reproduced and circulated by and between NHS Hammersmith and Fulham, related networks and officially contracted third parties only. This includes transmission in any form or by any means including photocopying, microfilming, recording and file transfer. This publication is copyright under the Copyright, Designs and Patent Act All rights reserved. Outside of NHS Hammersmith and Fulham, related networks and officially contracted third parties, no part of this publication may be reproduced or transmitted in any form or by any means, including photocopying, microfilming, recording and file transfer, without the written permission of the copyright holder, application for which should be made in writing to the following address (and marked re: permission ). Such written permission must always be obtained before any part of this publication is stored in a retrieval system of any nature, or electronically. Where any of the copyright items within this publication are being republished or copied to others, the source of the material must be identified and the copyright status acknowledged. About the NHS Hammersmith and Fulham logo The NHS Hammersmith and Fulham logo is Crown copyright. Logos are not covered by OPSI licensing. The NHS Identity guidelines state that 'the NHS logo can only be used by NHS organisations, or on services and information that the NHS has had some involvement in'. These guidelines also apply to the use of the NHS Hammersmith and Fulham logo. About the QOF+ logo QOF+, QOF Plus, the Plus roundel and the QOF+ ribbon are trademarks of NHS Hammersmith and Fulham. If you are interested in replicating the QOF+ scheme in your PCT we would be delighted to share copyright and assist with localising the scheme. For permission and information please contact: If you require further information about any other aspect of QOF, please contact: Additional QOF+ resources and content are available to download from: requires N3 connection

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4 Contents Introduction to QOF Context... 1 Defining and measuring the quality of healthcare... 1 The quality and outcomes framework (QOF)... 2 Impact of the quality and outcomes framework... 2 Future changes to the quality and outcomes framework... 2 Limitations of the quality and outcomes framework... 3 The role of healthcare in addressing health inequalities... 3 Effect of measurement on health inequality... 4 Why have a local QOF?... 5 How might a local QOF operate in practice?... 6 Why have a local QOF for Hammersmith and Fulham?... 6 The need for clinical engagement... 6 Aims... 7 Summary of indicators... 9 Higher thresholds for existing Clinical QOF indicators... 9 New clinical QOF+ indicators New non-clinical QOF+ indicators QOF+ report on cardiovascular disease prevention Proposed indicators Creation of practice CVD at-risk register Background Priority and relevance to national policy Prevalence of condition Associated morbidity and mortality Local context Review of evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References... 26

5 QOF+ report on alcohol Proposed indicators Background Priority and relevance to national policy Prevalence of condition Associated morbidity and mortality Local context Review of evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References QOF+ report on smoking Proposed indicators Background Priority and relevance to national policy Prevalence of condition Associated morbidity and mortality Local context Review of evidence to support proposed indicators Degree of perceived support from professionals Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References QOF+ report on smoking in pregnancy Proposed Indicators Background Priority and relevance to national policy Prevalence of condition Associated morbidity and mortality Local context Evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References... 43

6 QOF+ report on breastfeeding Proposed Indicators Background Priority and relevance to national policy Prevalence of condition Associated morbidity and mortality Local context Review of evidence to support the proposed indicator Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health Impact Workload and training implications References QOF+ report on ethnicity Proposed Indicators Background Priority and relevance to national policy Demography Associated Morbidity and Mortality Local context Review of evidence to support proposed indicators Degree of perceived support from professionals Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References QOF+ report on records Proposed indicators Background Priority and relevance to national policy Prevalence of conditions Local context Review of evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References... 63

7 QOF+ report on new patient screening Proposed indicator Background Priority and relevance to national policy Prevalence of condition Associated morbidity and mortality Local context Review of evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References QOF+ report on patient information Proposed indicators Background Priority and relevance to national policy Local context Review of evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References QOF+ report on patient experience Proposed indicators Background Priority and relevance to national policy Local context Review of evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References... 83

8 QOF+ report on patient safety Proposed indicators Background Priority and relevance to national policy Local context Review of evidence to support the proposed indicators Degree of perceived professional consensus Degree of perceived support from patients and carers Impact on health inequalities Health impact Workload and training implications References Training and support requirements for QOF Introduction Training and support requirements for selected existing QOF indicators Training and support requirements for new QOF+ indicators... 92

9 Appendix 1 Background to the QOF+ development process Composition of the QOF+ development group Process employed by the QOF+ development group Approach to development of the scheme Appendix 2 Methodology for the extension of existing clinical QOF targets Selection of candidate existing indicators for revised upper thresholds Methodology for revised target setting for existing clinical indicators Methodology for point allocation for existing clinical indicators Minimum attainment thresholds Exception reporting List turnover References Appendix 3 Current levels of attainment and exception reporting for existing clinical indicators 116 Purpose of these data Data sources Using the graphs Asthma BP CHD CHD CHD CS DM DM DM MH Stroke Stroke Appendix 4 Methodology for the design and development of the new indicators for QOF Methodology for the creation of new indicator areas long list Consultation with local stakeholders to select priority areas for the development of QOF+ indicators Methodology for the development of new indicators Consultation with local practices Assessment of new indicators Response to feedback on proposed new indicators Final consultation with local practices Methodology for point allocation for the new QOF+ indicators Communication with the PCT s health informatics team Appendix 5 Methodology for the development of the training and support package Development of the training and support package Results of data analysis of practice achievement for selected existing QOF indicators Results of practice training and support needs assessment Appendix 6 Summary of the QOF+ scheme

10 Credits Project board Josip Car Miles Freeman Yvonne Odegbami Azeem Majeed Arti Maini Becky Wellburn Christopher Huckvale Sian Clapton Hakan Akozek Xavier Yibowei Project Executive, Academic & Clinical lead Project Executive, Management lead Project Manager Academic and Clinical Advisor Clinical QOF+ Coordinator Non-clinical QOF+ Coordinator QOF+ Analytics Project Finance Officer Chief Information Officer Head of Informatics Project governance Hakan Akozek Josip Car Frances Donelly Miles Freeman Christopher Millett Alison Williams Dagmar Zeuner Deputy Director of Informatics and Quality PEC Chair & Medical Director Project Director for Primary Care Quality Director of Primary Care and Commissioning Consultant in Public Health Director of Finance Director of Public Health Contributors Riyadh Alshamsan (Doctoral researcher in health economics) Josip Car (PEC Chair & Medical Director, GP and Director of e Health Unit) Miles Freeman (Interim Director of Primary Care) Christopher Huckvale (Honorary research associate in e Health) Elizabeth Koshy (Academic GP & honorary clinical research fellow) Arti Maini (Academic GP & honorary clinical research fellow) Azeem Majeed (Head of Department and Professor of Primary Care) Christopher Millett (Academic Consultant in Public Health) David Morley (Health informatics team) Sam Nemonique (GP on clinical leadership training) Shanker Vijayadeva (GP & honorary clinical research fellow) Jill Waddingham (QOF+ Resource Pack Co-ordinator) Becky Wellburn (Head of Primary Care Commissioning) Xavier Yibowei (Health informatics team) Dominik Zenner (GP and Specialist Registrar in Public Health) Dagmar Zeuner (Director of Public Health)

11 Delphi local stakeholder consultation group Josip Car, Miles Freeman, Sheraz Khan, Paul Skinner, Tony Willis, Dagmar Zeuner Health informatics team Hakan Akozek, Christopher Huckvale, David Morley, Richard McSharry, Xavier Yibowei

12 Acknowledgements We are indebted to the valuable contribution made by the following individuals and groups. Dr Ike Anya Dr Mark Ashworth Professor Richard Baker Patricia Cadden Christopher Corfield Gloria-Anne Cox Dr Tim Doran Professor Colin Drummond Rachel Haffenden Lynne Jones Professor Helen Lester Christine McCrudden Professor Martin Roland Professor Aziz Sheikh Dr Michael Soljak Tom Stevenson Dr Richard Williams Consultant in Public Health, NHS Hammersmith and Fulham Kings College London University of Leicester Senior Substance Misuse Commissioning Manager London Borough of Hammersmith and Fulham Chief Pharmacist, NHS Hammersmith and Fulham Hammersmith and Fulham TB Action Group University of Manchester Kings College London Hammersmith and Fulham TB Action Group Designated Nurse for Child Protection Hammersmith and Fulham University of Manchester Hammersmith and Fulham TB Action Group University of Manchester University of Edinburgh Imperial College, London Head of Communications, NHS Hammersmith and Fulham Lambeth PCT The NHS Information Centre GPRD Group, Medicines and Healthcare Products Regulatory Agency Professional Executive Committee (PEC), NHS Hammersmith and Fulham Planning and Strategy Group, NHS Hammersmith and Fulham We would like to thank all the general practices of Hammersmith and Fulham who participated in the QOF+ consultation process. In addition, we would like to acknowledge the work of the QOF Review; a collaboration between the Universities of Birmingham and Manchester, the Society of Academic Primary Care and the Royal College of General Practitioners which is led by co-directors Professors Richard Hobbs (UoB) and Helen Lester (UoM). We based the structure of the QOF+ reports on that used in the reports produced through the QOF Review.

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14 Foreword QOF Plus has high ambition - to deliver world class healthcare. It focuses on helping people live healthier and longer lives, and above all aims to dramatically reduce health inequalities. To achieve this vision of better care for all QOF Plus builds on existing systems for quality in primary care and uses the best international evidence to extend these. We know that improving quality is not easy. Yet we also know that it is possible when priorities and the approach to change are right. With QOF Plus we have focused on what matters and makes a difference for both patients and clinicians. We have built into the implementation the best evidence on support for quality improvement. In particular, we want to ensure that individual practices and clinicians are enabled in transforming their clinical practice to make it of consistently high quality. This publication is accompanied by a support resource pack, guidance on business and financial rules, EMIS and Vision templates for health monitoring, details of a series of training events, visits and workshops. Most importantly, QOF Plus is supported by a committed clinical, academic and management team which aims to provide a range of multimodal supportive strategies to address, in real time, areas of challenge. This is the most significant investment into quality improvement in primary care since the introduction of QOF. This innovative scheme, developed jointly with experts in our local Department of Primary Care and Social Medicine at Imperial College, combines a strong evidence-based approach with meaningful engagement and consultation with local practices and stakeholders. QOF Plus has been designed in line with national guidance and addresses a range of important national and local health service priorities. It builds on the analysis of the public health needs of Hammersmith and Fulham, and on what local people have told us they want. Advice offered by national and international experts in health care quality improvement has played a significant role in helping determine the vision and implementation strategy for QOF Plus, ensuring that we learn from past experience in the field. The key individuals involved in designing and developing QOF Plus believe passionately in and are fully committed to the principles embodied by the scheme, namely achieving excellence in healthcare for all people and reducing health inequalities; ensuring the healthcare needs of those most vulnerable are addressed. This team is championing the scheme and will, in partnership with patients and colleagues in primary care, work to make it a success. I am sincerely grateful to all that have contributed to this important project that brings new dynamism to primary care embodying some of the key principles of Lord Darzi s Next Stage Review. I believe QOF Plus will make a real difference to the people of Hammersmith and Fulham. I also hope that this work will make a valuable contribution to the current national debate about the future direction of QOF, and serve as a model for other PCTs wishing to initiate similar schemes. Sarah Whiting CEO, NHS Hammersmith and Fulham, December 2008

15 Executive summary Introduction Previous work has highlighted several limitations of the national Quality and Outcomes Framework (QOF) including insufficient focus on health outcomes, primary prevention, prioritised local health needs and benefits. QOF may not encourage practices in reaching the more challenging patients, as practices do not receive further incentives once they have received the upper payment threshold. It is anticipated that introduction of a local QOF will help address these limitations. Aims This document describes a joint venture by NHS Hammersmith and Fulham and the Department of Primary Care and Social Medicine at Imperial College London to design and develop a local QOF for Hammersmith and Fulham (QOF+) which is in line with current national guidance, developed through the process of effective clinical engagement and which aims to have a greater emphasis on prevention, address local needs, accelerate improvement and reduce inequity. Methodology Engagement with local practices and other local provider services, feedback from patients and discussions with national and international experts in health care quality improvement provided insights which informed the development of the scheme. A number of existing QOF indicators were identified as candidates that might benefit from additional incentivisation through the provision of revised upper targets. Indicator selection was weighted towards those whose attainment confers significant potential health benefits at a population level and where current attainment in Hammersmith and Fulham is below that seen nationally. Potential sources for new indicator areas were identified and prioritised on the basis of being both local and national priorities. These were subjected to a structured consultation with local stakeholders to select areas for indicator development for the first year of the scheme through a consensus process. Literature reviews of the evidence base were undertaken for each selected indicator area to inform development of indicators. Proposed new indicators were assessed using the Organisation for Economic Cooperation and Development (OECD) criteria of importance, scientific soundness and feasibility. Each indicator was also assessed for clarity. This assessment was informed by the views of local practices, a local stakeholder panel (through a structured consultation with the aim of achieving consensus for the clinical and records domains), local provider services and national and international experts in the proposed indicator areas.

16 Like QOF, QOF+ includes a combination of all-or-northing and payment stage indicators, re-uses the concept of exception reporting and determines remuneration using a system of population and prevalence-weighted point allocation. The PCT Health Informatics Team was consulted to ensure that proposed indicators would work within primary care IT systems. The development of a training and support package to support QOF+ was informed by consultation with local and national experts, analysis of data on achievement for existing QOF for individual practices, and a training and support needs assessment conducted among all local practices. Outcomes Through QOF+, practices will be rewarded with QOF+ points for achievement of higher thresholds for a selected number of existing national QOF indicators including the following: Asthma 6, BP 5, CHD 6, CHD 8, CHD 10, CS 1, DM 12, DM 17, DM 20, MH 6, Stroke 6, Stroke 8. Additionally, practices will be rewarded for achievement of new QOF+ indicators which have been developed in clinical and non-clinical domains covering the following areas: Cardiovascular Disease Primary Prevention, Alcohol, Smoking Cessation (including Smoking in Pregnancy) Breastfeeding, Ethnicity, Records, New Entrant Screening (for Tuberculosis), Patient Information, Patient Experience and Patient Safety. Anonymised medical records of all registered patients will be stored centrally by the PCT through the use of the APOLLO IT system by practices. This will enable analysis of performance, improved practice profiling, equity assessment using patient-level data, and provision of monthly feedback of performance to practices, as part of a wider training and support package which has been developed to support QOF+. Copyright NHS Hammersmith and Fulham 2008 Copyright ehealth unit, Department of Primary Care and Social Medicine, Imperial College 2008

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18 Support with QOF+ If you have a problem with any of the IT aspects of QOF+, please contact: This service is available to NHS Hammersmith and Fulham practices only. Additional QOF+ resources and content are available to download from: requires N3 connection For all other enquiries: For general help and support with any aspect of QOF+, there is a dedicated address: Hammersmith and Fulham practices can also contact their commissioning manager.

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21 Introduction to QOF+ Improving the quality of primary care services in Hammersmith and Fulham Context The purpose of this paper is to provide the rationale and describe the process for implementing a major quality improvement initiative for primary care services in Hammersmith and Fulham, called QOF+. The initiative has been developed by NHS Hammersmith and Fulham in partnership with the ehealth unit of the Department of Primary Care & Social Medicine at Imperial College London. NHS Hammersmith and Fulham has identified quality improvement in primary care as a key local priority. The PCT has earmarked over 2 million annual funding to implement a comprehensive local financial incentive scheme (QOF+) over the next three years (2008/09, 2009/10, 2010/11). The aims of this scheme are to achieve a step-change in quality and address local priorities. Subject to a positive evaluation, this funding is likely to be extended beyond this period. Defining and measuring the quality of healthcare There are currently no internationally agreed definitions of healthcare quality. Maxwell (1983) offers six dimensions of quality in healthcare including appropriateness, equity, accessibility, effectiveness, acceptability and efficiency. One of the most widely adopted definitions of quality is provided by the Institute of Medicine: "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 2001). Performance indicators are designed to measure the extent to which health services meet this goal (Majeed, 1995). There has been an increased interest in measuring the quality of care over the past decade. In parallel, there have been significant developments in databases, both administrative and clinical, which have enabled collection of routine information on quality. These factors have significantly influenced the development and implementation of performance indicators (Majeed et al., 2007). International evidence underlines the importance of high quality primary care in achieving an effective and efficient health care system and in improving population health (Starfield, 2001). Whilst recent investment in quality initiatives in the UK has led to considerable improvements in primary care, the quality of service provision remains variable in many areas (Gray et al., 2007; Hippisley-Cox et al., 2004). 1

22 The quality and outcomes framework (QOF) April 2004 saw the introduction of the Quality and Outcomes Framework (QOF) as part of the New Contract for General Practitioners where pay was linked to performance with the purpose of driving up standards for primary care. The framework includes quality and performance indicators in a number of domains, including clinical, organisational and patient experience, as well as additional areas such as cervical screening (Roland et al., 2004). The quality measures in 2004 were largely drawn from existing national guidelines, and were designed to reflect widely accepted standards of clinical care. The contract was significantly revised in 2006 following a renegotiation, with the addition of nine areas, changes in indicators and increased thresholds for payment. Impact of the quality and outcomes framework GPs have achieved high scores in the QOF in each of the first three years of the scheme. In practices in England achieved an average of points, (95.5 percent of the 1,000 available). This compares with an average achievement of 96.2 per cent in and 91.3 percent in against the 1,050 points then available (National Audit Office, 2008). Early data suggests the introduction of the QOF has shown moderate improvements in outcomes for patient care in some long term conditions such as asthma and diabetes, but not for others such as coronary heart disease (Campbell et al., 2007). Future changes to the quality and outcomes framework Built into the new GMS contract is the expectation that QOF will evolve over time. The focus in the first few years of QOF has been on process measures as a first step towards achieving good outcomes. Lester (2008) further comments that In future, perhaps pay for performance schemes should be actively designed with health inequalities in mind. As part of the NHS Next Stage Review, the Department of Health announced proposals for further developing the Quality and Outcomes Framework (QOF) including an independent and transparent process for developing and reviewing indicators. The Review outlined plans to discuss with the National Institute for Health and Clinical Excellence (NICE) and with professional and patient groups how this new process should work, and to explore the possibility of allowing PCTs greater flexibility to select indicators (from a national menu) that reflect local health improvement priorities (Darzi, 2008). The National Audit Office (NAO) report on GP contract modernisation (National Audit Office 2008) recommended that the Department of Health should: develop a long term strategy to support yearly negotiations on QOF, and develop QOF based on patients needs and in a transparent way, base the strategy more on outcomes and cost effectiveness, and agree to allocate a proportion of QOF indicators for local negotiation at Strategic Health Authority (SHA) or PCT level. 2

23 The Department of Health is currently consulting on the proposal to ask NICE to oversee a new independent, transparent and objective process for developing and reviewing QOF clinical and health Improvement indicators for England from 1 April 2009 (DoH, 2008). The Department of Health is also consulting on the proposal that Primary Care Trusts (PCTs) should have flexibility to select additional indicators from the NICE menu to reflect local priorities. The Royal College of General Practitioners is planning to develop and roll out nationally by 2010 an accreditation scheme for GP practices. It is proposed that this scheme will serve as a vehicle to drive organisational quality improvement, and this is likely to have a significant impact on the arrangements for incentivising organisational quality through the Quality and Outcomes Framework (National Primary Care Research and Development Centre, 2008). Limitations of the quality and outcomes framework The National Audit Office (2008) and Fleetcroft el al. (2006) have highlighted a number of limitations of the national QOF: incentivised clinical areas in QOF may not reflect local population health needs, indicators are insufficiently focused on health outcomes, and rewards are insufficiently aligned with prioritised health need or health benefit. Payment thresholds have arguably been set too low, so that standards recommended in national clinical guidelines are not being achieved for most patients (Fleetcroft et al., 2008). There is some evidence that improvements in care associated with QOF have not occurred in all groups, e.g. ethnic minorities, thereby potentially worsening health inequalities (Gray et al., 2007). Quality indicators in QOF have not been sufficiently weighted towards primary prevention (Darzi, 2008). In addition, Short (2007) notes discrepancies between QOF and NICE guidance in certain areas and comments that there needs to be some clarity and stream-lining of guidance between primary care and major clinical governing bodies. NICE is currently examining the fit between QOF and the evidence-based NICE guidelines (Leech, 2008). The role of healthcare in addressing health inequalities The principle of social justice incorporated into the Physician s Charter (Medical Professionalism Project: ABIM Foundation 2002) states that the medical profession must promote justice in the healthcare system and that physicians should work actively to eliminate discrimination in healthcare, whether based on race, gender, socio-economic status, ethnicity, religion or any other social category. One of the professional responsibilities included in the Physician s Charter involves improving access to care. This requires that physicians must individually and collectively strive to reduce barriers to equitable health care. 3

24 Effect of measurement on health inequality Mant (2008) comments that in everyday clinical practice, variability in usual care matters most at the tail-end of the distribution where poor care can lead to adverse outcomes including avoidable death. Evidence from epidemiological studies suggest that while effective regular mechanisms for dealing with poor care are essential, a more effective approach is to develop strategies for raising average performance, and therefore shifting the whole distribution (Rose et al., 1990). An example of this is the introduction of cervical smear targets for UK general practices in The highest targets were achieved rapidly by practices in affluent areas, and this resulted in an initial widening of the health inequality gap. However, practices in more deprived areas caught up over the next few years, thereby reducing inequality (Baker et al., 2003; Middleton et al., 2003). This phenomenon has been termed the inverse equity hypothesis (Victora et al., 2000). This hypothesis predicts that the benefits of new public health interventions are initially experienced by the wealthier sector of the population and later by the poor, increasing the inequity ratio. However, once the poor have experienced benefits and a ceiling effect is reached in the richer population, the inequity ratio which initially increases, then decreases. Although the Quality and Outcomes Framework was not designed to tackle health inequalities (Roland, 2004), there is evidence of the inverse equity hypothesis being relevant to QOF. Data is now emerging which suggests that from a longer term perspective, more equitable healthcare is being generated following the introduction of QOF (Lester, 2008). Ashworth et al. (2008) assessed the effects of social deprivation on levels of BP monitoring and control using data from over 97% of practices in England over the first three years of the QOF. They found that: Since the reporting of performance indicators for primary care and the incorporation of pay for performance in 2004, blood pressure monitoring and control have improved substantially. Improvements in achievement have been accompanied by the near disappearance of the achievement gap between least and most deprived areas. Doran et al. (2008) looked at overall achievement in 48 of the clinical indicators in QOF and found that median achievement score increased across the board, with the gap in median achievement between practices in the most and least deprived areas reducing considerably. The evidence suggests that low scoring practices in deprived areas also seem just as able to improve the quality of their care (as measured by the Framework) as low scoring practices in more affluent areas (Lester, 2008). Lester (2008) further comments that: Overall, the financial incentives seem to have reached areas of high need relatively effectively for most targets. An important subsidiary message is the need to take a long term view when interpreting the effects of quality measures on health inequalities. However, there remains concern that QOF may not encourage practices in reaching the more challenging, hard-to-reach patients, as practices do not receive further incentives once they have achieved the 90% upper threshold for payment (National Audit Office, 2008). This means practices can receive maximum points and payment for every clinical indicator before all eligible patients receive indicated care. Fleetcroft et al. (2008) comment that this can result in an incentive ceiling effect with associated reductions in health gains, and state that there may be no rationale for maximum target thresholds to be set below 100% as there are comprehensive reasons for exception reporting any patient who would not theoretically benefit from the indicated care. Setting and rewarding achievement of higher thresholds for selected existing 4

25 QOF indicators may therefore help to address this issue, with the aim of achieving additional health gains in a more challenging group of patients. Why have a local QOF? Local Enhanced Services (LES) already provide scope for local development within the GMS contract. The purpose of these is to allow PCTs to tackle local problems not addressed in the national QOF. These may include a greater emphasis on prevention and strategies designed to reduce inequity. It is anticipated that introduction of a local QOF would confer a number of advantages, including more robust performance reporting, mainstreaming quality through templates and coverage of a greater number of areas. The concept of developing a local QOF has recently received backing from the National Audit Office (2008) and the NHS Next Stage Review (Darzi, 2008). Development and implementation of a local QOF may also contribute to PCTs fulfilling their functions as World Class Commissioners. The Department of Health describes World Class Commissioners as being central to a self-improving NHS. They will operate as learning organisations, seeking and sharing knowledge and skills. World class commissioners will also be stimulating provider and clinical innovation through improvements in experienced quality, access and outcomes (DoH, 2008). As part of this commissioning process, PCTs are required to invest locally to achieve the greatest health gains and reductions in health inequalities, at best value for current and future service users. The World Class Commissioning programme (DoH, 2008) outlines a series of competencies which commissioners will need to reach world class status. These are: locally lead the NHS work with community partners engage with public and patients collaborate with clinicians manage knowledge and assess needs prioritise investment stimulate the market promote improvement and innovation secure procurement skills manage the local health system make sound financial investments 5

26 How might a local QOF operate in practice? There is ongoing debate about how a local QOF could work in practice. The Department of Health has proposed that to help address local health needs more effectively, PCTs should be able to select local indicators from a national menu of indicators, for use in local voluntary incentive schemes (DoH, 2008). An alternative is for indicators to be developed locally by PCTs. However, there are practical limitations associated with this approach including: the need for technical expertise in the development of evidence-based indicators and business rules for extraction of clinical data from GP systems; the IM&T support required to extract data from clinical systems and to link this with payment calculations (DoH, 2008). Why have a local QOF for Hammersmith and Fulham? Evaluations of recently introduced LES and local Shared Care schemes (including CVD Primary Prevention, Smoking Cessation and Alcohol) in Hammersmith and Fulham highlighted a number of problems with these schemes, in terms of their complexity and design and the level of uptake by practices. These highlight a need for widespread implementation in a way that is easily understood. There is also a need to reduce health inequalities and recognition that QOF may be a vehicle to achieve this. Although it has been proposed that PCTs should have flexibility to select local indicators from a national menu published by NICE, the infrastructure required to support development of local QOFs through this approach is not anticipated to be in place until 2011/12 at the earliest (DoH, 2008). It was therefore proposed that NHS Hammersmith and Fulham would develop a local QOF scheme to run initially for 3 years from 2008/9-2010/11, with technical expertise in indicator development being provided by the Department of Primary Care and Social Medicine at Imperial College London in conjunction with national and international experts in this field, and IM&T support being provided by the PCT s Health Informatics Team. The need for clinical engagement Effective local clinical engagement is crucial to the success of service improvement initiatives and its integral role has been highlighted in the competencies of World Class Commissioning (DoH, 2008) and by The NHS Alliance (2003) which states that front-line clinical staff should be effectively involved in redesign, service provision and in ensuring services are used costeffectively. The NHS Alliance further highlights that the engagement of front-line professionals at a strategic level would allow PCTs to draw on a bank of untapped knowledge resulting from the wider experiences of primary care. The involvement of local practices in helping shape QOF+ was therefore seen as a central element of the design and development of the scheme. 6

27 Aims This paper describes the design and development of a local QOF for Hammersmith and Fulham which is in line with current national guidance, developed through the process of effective clinical engagement and which aims to have a greater emphasis on prevention, address local needs, accelerate improvement and reduce inequity. References Ashworth M, Medina J, Morgan M (2008). Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the "quality and outcomes framework." British Medical Journal 337:a2030 Baker D, Middleton E (2003) Cervical screening and health inequality in England in the 1990s. Epidemiological Community Health 57: Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of Primary Care in England with the Introduction of Pay for Performance (2007). New England Journal of Medicine 357: Darzi A (2008) High Quality Care for All, the final report of the NHS Next Stage Review Final Report by Lord Darzi The Stationary Office. London Department of Health (2008) Developing the Quality and Outcomes Framework: Proposals for a new, independent process. [Online, Accessed November ] Available at: Department of Health (2008) World Class Commissioning. [Online, Accessed August ] Available at: x.htm 7

28 Doran T, Fullwood C, Kontopantelis E, Reeves D (2008). Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet 372: Fleetcroft, R and Cookson, R (2006) Do the incentive payments in the new NHS contract for primary care reflect likely population health gains? Journal of Health Care Research and Policy 11: Fleetcroft R, Steel N, Cookson R, Howe A (2008) Mind the gap!" Evaluation of the performance gap attributable to exception reporting and target thresholds in the new GMS contract: National database analysis. BMC Health Services Research 8: 131 Gray J, Millett C, Saxena S, Netuveli G, Khunti K, Majeed A (2007) Ethnicity and Quality of Diabetes Care in a Health System with Universal Coverage: Population-Based Cross-sectional Survey in Primary Care. Journal of General Internal Medicine 22: Hippisley-Cox J, O'Hanlon S, Coupland C (2004). Association of deprivation, ethnicity, and sex with quality indicators for diabetes: population based survey of patients in primary care. British Medical Journal 329: Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press Leech P (2008) QOF; Key benefits and challenges in long term conditions management. [Online, Accessed August ] Available at: Lester H (2008) The UK Quality and outcomes framework. British Medical Journal 337:a2095 Mant D (2008) The problem with usual care. British Journal of General Practice 58:755-6 Majeed FA, Voss S (1995). Performance indicators for general practice. British Medical Journal 311: Majeed FA, Lester H, Bindman AB (2007) Measuring Quality through Performance: Improving the quality of care with performance indicators. British Medical Journal 335: Maxwell R (1983) Seeking quality. Lancet :45 8 Medical Professionalism Project: ABIM Foundation (2002): Medical Professionalism in the New Millennium: A Physician Charter. Annals of Internal Medicine 136: Middleton E, Baker J (2003) Comparison of social distribution of immunisation with measles, mumps, and rubella vaccine, England, British Medical Journal 326:854 National Audit Office (2008) NHS Pay Modernisation: New Contracts for General Practice Services in England. The Stationary Office. London Roland M (2004). Linking physician pay to quality of care a major experiment in the United Kingdom. New England Journal of Medicine 351: Rose G, Day S (1990). The population mean predicts the number of deviant individuals. British Medical Journal 301: Short K (2007) QOF vs NICE. British Journal of General Practice 57:748 Starfield B (2001). New paradigms for quality in primary care. British Journal of General Practice 51: Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E (2000). Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 356:

29 Summary of indicators Higher thresholds for existing Clinical QOF indicators Practices will receive a fixed number of QOF+ points for reaching or exceeding a revised upper threshold for the indicators detailed below. Point awards will be in addition to those allocated under QOF and based on attainment at close of business on March QOF QOF+ Indicator Upper Threshold Threshold & (Tolerance) Points ASTHMA 6. The percentage of patients with asthma who have had an asthma review in the previous 15mths BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 CHD 6. The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 CHD 8. The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the previous 15 months) is 5mmol/l CHD 10. The percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded) CS 1. The percentage of patients aged from 25 to 64 whose notes record that a cervical smear has been performed in the last five years DM 12. The percentage of patients with diabetes in whom the last blood pressure is 145/85 70% 95% (3%) 10 70% 90% (2%) 29 70% 98% (1%) 6 70% 87% (2%) 7 60% 87% (1%) 14 80% 88% (7%) 35 60% 86% (1%) 5 Continues overleaf 9

30 Continued QOF QOF+ Indicator Upper Threshold Threshold & (Tolerance) Points DM 17. The percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5mmol/l DM 20. The percentage of patients with diabetes in whom the last HBA1c is 7.5 or less in the previous 15 months MH 6. The percentage of patients on the register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate STROKE 6. The percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 in the previous 15 months STROKE 8. The percentage of patients with a history of TIA or stroke in whom the last total cholesterol (measured in the previous 15 months) is 5 mmol/l or less 70% 88% (1%) 9 50% 77% (1%) 20 50% 97% (1%) 3 70% 96% (1%) 6 60% 85% (1%) 5 Under the current QOF 2009/10 proposal, DM20 will be replaced by DM23, which lowers the target for HbA1c to 7.0. We recognise that attaining this more aggressive target will require significant effort involving potentially large numbers of patients. To reward practices as they progress towards the revised goal, we propose to retain DM20 within QOF+ until the end of March Since DM20 attainment status will no longer be available through QMAS, feedback will instead be provided through the same mechanism of monthly reporting used for the new QOF+ clinical indicators. During consultation with practices concern was raised about the possibility, with an allor-nothing payment mechanism, of receiving no remuneration where the revised target was missed through accidental failures involving small numbers of patients. A range of solutions were considered to address this including the use of payment ranges, similar to those of QOF but all were felt to distract from a key aim of the revised targets, which is to drive performance towards the best seen at a national level. It was decided to retain the single upper threshold but to introduce a tolerance (bracketed figures in the table above) which lowers the threshold by the specified amount. Attainment lying at or above this lower figure will be remunerated by receiving half the available points. Where the point number is odd, the points will be divided unequally with the balance in favour of the tolerance payment. The existing 3-month exemption for newly registered patients will be respected across these and the newly introduced indicators. 10

31 New clinical QOF+ indicators New indicators are distinguished from existing QOF targets by the plus (+) prefix. Blanket minimum attainment thresholds will no longer be included in year 1 of the QOF+ scheme ( for more information see Appendix 2, Section A2.4). Point awards will be based on attainment at close of business on November Cardiovascular disease prevention Chapter 3 (p19) Indicator QOF+ points Payment stages + CVD PREVENT 1. The percentage of patients on the Practice CVD At-Risk Register whose notes have a Blood Pressure recorded in the previous 17 months + CVD PREVENT 2. The percentage of patients on the Practice CVD At-Risk Register whose notes have a record of BMI measured in the previous 17 months + CVD PREVENT 3. The percentage of patients on the Practice CVD At-Risk Register whose notes have a baseline record of total and HDL cholesterol recorded in the previous 17 months + CVD PREVENT 4. The percentage of patients on the Practice CVD At-Risk Register for whom there is a record of a fasting blood glucose in the previous 17 months + CVD PREVENT 5. The percentage of patients on the Practice CVD At-Risk Register whose notes have a record of family history of CHD in first degree relatives (parents, brothers, sisters, or children of a patient) + CVD PREVENT 6. The percentage of patients on the Practice CVD At-Risk Register whose notes have a record of family history of diabetes in first degree relatives (parents, siblings, or children of a patient) + CVD PREVENT 7. The percentage of patients on the Practice CVD At-Risk Register who have been offered lifestyle advice on exercise, and appropriate dietary changes within the previous 17 months + CVD PREVENT 8. The percentage of patients on the Practice CVD At-Risk Register who have been offered statin therapy (in line with 2008 NICE guidance on Lipid Modification) as part of their primary prevention management strategy % % % % % % % % It is prerequisite that in order to receive payment for + CVD PREVENT 1, practices have achieved the existing QOF RECORDS 11 Indicator (The BP of patients aged 45 and over is recorded in the preceding 5 years for at least 65% of patients.) 11

32 Alcohol Chapter 4 (p27) Indicator QOF+ points Payment stages + ALCOHOL 1. The percentage of patients on one or more practice registers for CVD At-Risk, Diabetes, Stroke and TIA, Hypertension and CHD who have had AUDIT-C or FAST recorded on the practice system within the previous 17 months + ALCOHOL 2. The proportion of patients who screen positive using either AUDIT-C or FAST within the previous 17 months who are subsequently recorded as having a brief intervention for alcohol misuse % % It is prerequisite that in order to receive payment for + ALCOHOL 2, practices shall have reached the lower threshold for + ALCOHOL 1. Smoking Chapter 5 (p33) Indicator QOF+ points Payment stages + SMOKING 1. The percentage of patients aged 15 years or older whose notes record smoking status in the past 17 months, or whose most recent recorded smoking status, recorded over the age of 25, indicates that they had never smoked + SMOKING 2. The percentage of patients aged 15 years or older who smoke whose notes contain a record that smoking cessation advice or referral to a local smoking cessation service has been offered within the previous 17 months % % Smoking in pregnancy Chapter 6 (p39) Indicator QOF+ points Payment stages + SMOKING IN PREG 1. The percentage of pregnant women whose notes record their smoking status at the time of their first booking appointment in primary care + SMOKING IN PREG 2. The percentage of pregnant women who smoke whose notes contain a record that at the time of their first antenatal booking appointment in primary care they have been given smoking cessation advice and details of the local NHS Stop Smoking Services and the NHS pregnancy smoking helpline ( ) % % 12