After five years without change, the Quality and Outcomes Framework (QOF) has been updated this year.
Although some have described it as the biggest change ever to the QOF, it certainly isn’t; the changes would have been considered quite routine a decade ago.
Most of this year’s changes can be split into two broad categories. Firstly there has been a clear out of indicators to free up some points for two new quality improvement (QI) indicators.
Secondly, outcome indicators (measurements of blood pressure, HbA1c etc) now have some adjustment for patient age and frailty. The aim here is to reduce overtreatment where patients are most likely to suffer from side effects of medication.
A total of 74 points have been moved to the new QI indicators. The biggest transfer is of 16 points from the diabetes area with a further 10 from COPD and 9 from organisational indicators relating to cervical cytology. Other big losers are mental health, contraception and mental health.
See here for a summary of how previous indicators and points have changed.
All of the ‘administrative’ indicators that had to be manually declared on CQRS at the end of the year have gone. These include the indicator for providing literature to smokers, nine points around the administration of cervical cytology and palliative care meetings. All of these were paid without adjustment for disease prevalence and the points will have exactly the same value in the new QI indicators.
This also means that the palliative care area now only contains the disease register. In addition to this area, peripheral arterial disease and osteoporosis have been added to the list of ‘register only’ indicators. Epilepsy and learning disabilities already had only vestigial registers.
The points for these registers are still adjusted for disease prevalence, with the exception of palliative care. The osteoporosis register is particularly complicated, as it still has the different dates and criteria for patients depending on their age.
Of the 74 points that are being moved to the QI domain, 53 were in disease areas with prevalence adjustment.
On average, the move away from disease adjusted indicators will be neutral for practices. At the individual practice level, however, the changes could be large.
For example, the top 10% of practices for osteoporosis prevalence have around two and a half times the average prevalence, meaning for this group the loss of 6 points to QI is financially the equivalent of a 15-point loss.
There is only one truly new requirement in the clinical part of the QOF. This is that patients with a COPD dyspnoea symptom grade of three or greater should be referred for pulmonary rehabilitation. It will be important to have a process in place for this to happen, either by clinicians or as an administrative process.
Otherwise there have been changes to outcomes indicators, principally blood pressure levels.
Age now determines the blood pressure threshold that will apply. For patients under 80 years old at the end of the QOF year the blood pressure threshold in the CHD, hypertension and stroke areas is now 140/90 mmHg. For patients aged 80 and over it is 150/90 mmHg in each area.
These replace some tiered blood pressure indicators in each area. Under the previous tiered arrangement all patients were eligible for each indicator and, effectively, the payment was simply a bit higher for patients who achieved better blood pressure control.
The effects on practices of the age dependent indicators will depend on the makeup of the practice population. It is an irony of the QOF that it is the indicators with small numbers of patients that are the most significant.
To see how that works we can think about a practice with a very young population with only one patient over 80 years old on the hypertension register and ten patients under 80. That one elderly patient would be worth 8 points whilst each of the younger patients would be worth only 1.4 points each (or 14 between them).
The converse situation could play out in a practice that exclusively looked after patients in a nursing home. A very small number of patients could earn the practice quite substantial sums.
Prevalence adjustment will apply to the hypertension area as a whole, however the ages are distributed.
The diabetes area takes this a step further. There are separate indicators about the prescribing of statins depending on whether the patient has had coronary heart disease.
A little more dramatic is the removal of the mid-level blood sugar indicator, for patients with HbA1c levels of 64 nmol/mol or less (and the points that go with it), and the change to the higher indicator, HbA1c of 75 mmol/mol or less, so that this now applies to patients with moderate or severe frailty.
Frailty assessment has been part of the base contract for the last couple of years, although its use by practices is quite variable. The incentives in diabetes tend to make the diagnosis of frailty more attractive where patients have higher blood sugars and against the diagnosis in patients with an HbA1c of less than 59mmol/mol, although the intention is obviously that the diagnosis drives the blood sugar target rather than the other way around.
As the payment thresholds have not changed I think that these indicators will be a little easier this year, especially as a frailty diagnosis can be regarded as a form of partial exception reporting.
The new QI indicators are for this year in the areas of prescribing safety and end of life care, carrying a total of 74 points.
These indicators will change every year so there is not too much incentive to set up IT systems for them. They are in the form of an audit cycle, in three stages of ‘analyse, implement and reanalyse’. It makes sense to get started early on this.
There is a slight bias towards larger practices in the payments for these indicators, as each practice only needs to attend each meeting once. It is, however, worth clubbing together with other practices to share searches, templates and other tips. Most practices will be doing very similar things and so resources can be shared either locally or nationally.
Unlike the clinical areas of QOF, the payment is fixed so the key to maximising profitability is to work as efficiently as possible.
See a full run-down of retired and new indicators here.
Dr Gavin Jamie is a GP in Swindon and runs the QOF database
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