QOF Key benefits and challenges in long term conditions management Philip Leech Consultant adviser D

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QOF Key benefits and challenges in long term
conditions managementPhilip LeechConsultant
adviserDH and PCC

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QOF is.

• A support system to delivery quality care in an
  ordered and systematised way that will produce
  hugely better patient outcomes
• Will help to develop a high quality public
  health database
• produces a too heavily weighted bonus payment
  that has inhibited other developments in practice
• risks neglect of clinical areas not incentivised
  (e.g. osteoporosis).

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LTCs are.

• The terms management of long-term conditions /
  diseases and chronic condition / disease
  management have been used interchangeably. In
  October 2004, the Department of Health, adopted
  the newer terminology of Long term Conditions
• Chronic disease management is a system of
  coordinated healthcare interventions and
  communications for populations with long term
  conditions in which patient self care is
  significant (NHS Alliance 2004).
• Effective chronic disease management is based on
  generic approaches to managing specific
  conditions rather than condition specific
  approaches

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There has been high uptake of QOF by practices
and high achievement rates are almost universal

• Many practices are attaining a high proportion of
  points on offer, particularly in the clinical
  domain

Median points rising to 87 in 2005/6
High achievement in clinical domain
Year 2
Year 1
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The biggest impact has probably been on chronic
disease registers, a pre-condition for systematic
care

• broader policy initiatives have been supported
  on the ground by the Quality and Outcomes
  Framework (QOF). This rewards general practices
  for each person on their registers as well as for
  17 other indicators of good practice for each
  person. This has seen over 100,000 more people
  diagnosed with diabetes in the last year
  alongside improvement in all the other diabetes
  QOF indicators.

Source Improving diabetes services Four years
on. Available from DH website
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• But
• Do PCTs know
• what expected prevalence should be and
• whether need is met through QOF
• what qof points are most likely to be gamed
• For example.

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Black boxes show the range for the upper and
lower quartiles (50 of practices will be between
these limits) whilst the whiskers show the range
from minimum to maximum levels Distribution of
prevalence at practice level.
There may be a problem of over recording, for
example where some practices report prevalence of
hypertension in half their patients!
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Diabetes prevalence
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Defining Outliers register size
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QMAS reports crude prevalence rates not
adjusted for risk factors (age, sex ethnicity
etc) very high / low rates might be explained by
these factors Doncaster PCT have generated a tool
that refines expected prevalence rates for 7
conditions based on practice level
socio-demographic factors
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SMRs in CVD
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QOF Scores
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QOF is a rich data source practices and PCTs
can benchmark performance

• Services can benchmark their diabetes care
  through three indicators HbA1C (a
• measure of glucose control), blood pressure, and
  cholesterol levels. Figs show
• - The difference between each strategic health
  authority
• - The improvement within each strategic health
  authority, shown by the
• filled and unfilled circles, between 2004/5 and
  2005/6
• - And could show the variation amongst PCTs
  within each SHA and, of course, practices.

Source Improving diabetes services Four years
on. Available from DH website
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QOF however has fewer incentives to improve some
important aspects of care

• This shows that measurement of key indicators is
  excellent, but that
• there is still work to do on improving outcomes.
  Measurement is necessary but not sufficient.
• In diabetes for example, there needs to be a
  greater focus on ensuring that people with
  diabetes are encouraged to develop the skills,
  knowledge and above all motivation to improve
  their care in partnership with professionals.
  QOF is not currently set-up to deliver this, and
  is not directly relevant to practice-based
  commissioning of other services since the
  delivery of buyable person-intensive services
  is not its focus.

Source Improving diabetes services Four years
on. Available from DH website
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There are (differerent estimates) 11 -15 million
people with comorbidities QOF doesnt do
comorbidities
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In any case, whilst there are now a large number
of disease areas, there is no consideration of
some major areas, so there is no matching data
and on other things that affect health
status Osteoporosis 32 different sorts of
arthritis Various chronic bowel
syndromes Nutrition and anaemias Social factors
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There is evidence that quality and staff
satisfaction have improved since QOF

• Clinical care has improved following introduction
  of QOF, along with job satisfaction

I enjoy being given the autonomy to manage the
different diseases. because we are actually
meeting targets, patient care has definitely
improved. Practice Nurse
Quality measures continue to increase
accelerate in some cases since QOF
We developed this zero tolerance of blood
pressure. No-one is allowed to say Its a little
bit up, leave it . its not acceptable. Senior
GP
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Overall, there are many positives but also some
lessons from the first few years

• Still early days, overall learning has shown many
  positives with some clear lessons for England

• Lessons
• underestimate of baseline performance
• rise in GP compensation
• administrative workload
• GPs taking a higher proportion of practice income
  as personal income
• some indicators questionable
• not stretching enough
• not high impact
• need to move to more outcome focused measures
• focuses on only a minority of patients
• may disadvantage patients in deprived areas
• (since less likely to take part, GPs concentrate
  on low-hanging fruit)

• Positives
• champions prevention and quality based on
  evidence
• creates good practice across the system
• high compliance
• low variation
• World class clinical database basis for
  decision making at local and national levels
• moving towards longer term health and well-being
  outcomes the bar is rising
• foundation for shift to primary care and other
  policy directions
• enables role redesign and other new ways of
  working

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There have been criticisms of early QOF that its
clinical indicator set didnt correlate well with
possible population health gains

• QOF indicators are not optimally aligned with
  interventions and activities that will have the
  maximum impact on population health
• Cookson et al correlated evidence on the
  population health gains from cardiac prescribing
  interventions with the relevant QOF payments
• Plotted points associated with these
  interventions against likely lives saved p.a. per
  100,000, with a relatively poor fit.

Source Fleetcroft, R. and Cookson,, R. (2005)
Do the incentive payments in the new NHS contract
for primary care reflect likely population
health gains? Journal of Health Care Research
and Policy
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There has been an overall shift towards more
clinical outcome focused metrics

• Increasing emphasis on clinical performance and
  patient experience - from 65
• of points in 2005/6 to 76 in 2006/7

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The further development of QOF is up for debate

• Does the apparent high level of performance
  represent real improvement or simply changes in
  recording behaviour or gaming eg exceptions
  reporting?
• How much bigger can and should QoF get? Should
  it include points for persuading patients to go
  on self-management courses for example?
• What is the impact of the contract on internal
  professional motivation? Will GPs become pure
  profit-maximisers and subvert professional
  values?
• Is such a large investment a cost-effective use
  of resources given what else could be done with
  the money? Put bluntly is this a John Wayne
  contract? NICE are currently looking at the fit
  between QOF and its evidence-based guidelines.
• Can it be used to support other policy goals e.g.
  accreditation of practices, ensuring patients are
  offered more choice, practice-based commissioning
  etc?

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Pay for Performance pilots are ongoing in the
hospital sector in England a hospital QOF linked
to Practice-Based Commissioning?

• The Department sees considerable potential in
  adopting a pay for performance approach in
  England, complementary to the national tariff.
• This would involve setting financial incentives
  at contract level, based on performance across a
  range of relevant indicators, with a bonus
  payment for service excellence.
• Work is underway to pilot this type of approach
  in NHS North West, based on the US Premier Group
  model.
• Lessons from this pilot will be examined, to
  consider the potential for its wider adoption
  across the NHS.