How QOF is evolving

The 2013/14 QOF changes may be just the start, writes Stephen Robinson.

As the GP contract dispute rumbles on across most of the UK, perhaps the only consensus between GP leaders and politicians is that, after nine years, the QOF faces its biggest transformation yet.

But, looking beyond April, the signs are that such changes will keep on coming.

Back in April 2004, the virgin framework had just 10 disease areas. Eight years on, this has swollen to 22, along with entirely new and controversial targets, such as paying GPs to lower A&E admissions. In its 10th year, 2013/14, the whole framework stands to change again if, as expected in England, the organisational domain is dropped and the QOF shrinks by 10% (see chart, below).

Political priorities

Further shifts are likely, with political priorities to the fore as pressure on the NHS intensifies. This growing political influence looks set to be a stand-out feature from now on. Notwithstanding the quality and productivity indicators, thrust into QOF at the last minute in 2011, the influx of new dementia targets, tougher thresholds and a greater emphasis on public health all point to a QOF where ministers pull the strings.

The DH says the changes take money out of 'bureaucratic tick box' exercises and put it into front-line care. Announcing the changes in December, health secretary Jeremy Hunt said: 'Standards of care in this country must be world class, and we should continuously strive to improve. This is why the GP contract must change.'

Regional differences

Separate negotiations by devolved UK governments have created the first sizeable QOF split since the current GMS contract began in 2004.

In Scotland, many of the changes faced by GPs in England will be avoided, with only 'modest increases' in thresholds for 13 clinical areas and none above 90%. Although Scotland will also get most of NICE's recommended indicator changes, there are substantial tweaks in what will be included.

In Wales, the government wants a deal that would see NICE's indicator changes accepted, but again with local adaptations. The stricter, 12-month window for annual reviews faced by GPs in England is left out, while some organisational indicators have been retained.

In England, the breakdown of negotiations between the GPC and NHS Employers opened the door for the DH's proposed changes to be adopted wholesale. The GPC is adamant the plans will lead to five-figure losses in many practices. Although, as QOF statistics expert and Wiltshire GP Dr Gavin Jamie tells GP, the profession's achievements have surprised governments in the past (see 'GP expert view', below).

GPs' declining influence

In 2011, GPs warned it was becoming more difficult for the profession to influence the future of the QOF. That year, NICE withdrew direct stakeholder input for proposing new indicators, meaning stakeholders could only contribute to the creation of its quality standards and guidance that indirectly provide the basis of new targets.

Meanwhile, the DH retains its power to suggest indicators directly. At a recent meeting of QOF advisers last month, the department exercised this right by asking NICE to merge nine diabetes indicators (see 'All-or-nothing targets', right). It remains to be seen whether such requests will become more frequent.

An exasperated GPC continues to bemoan the plans. It has warned that some of the clinical changes to the QOF in England are 'unworkable', as some services to which GPs must refer under the new targets are not available across the country.

In response, a DH spokeswoman told GP: 'We are clear that improving patient care is our priority - GPs should only get additional funding for the quality of services they offer.

'It is not true to say the proposals for new indicators are unworkable. All of them are developed by NICE and are based on robust evidence. They were also piloted by NICE for at least six months.

'GP practices should be working with their CCGs to ensure that services that may improve their patients' health are available more widely.'

She added: 'We believe practices will rise to meet the new challenges.'

Undeterred, the GPC will run a series of roadshows in 25 locations across the UK in January and February to listen to GPs' views on the contract changes. The QOF will likely feature heavily in their concerns, as it has done in the committee's formal responses so far.

The GPC's objections regarding the QOF changes in England are numerous, ranging from losses in income to workload and impacts on clinical care and autonomy.

But it marks only the start of a tougher, new-look QOF, with greater turnover of indicator thresholds forcing practices to work harder to chase points (see 100% thresholds, below). Factor in new tailored targets (see 'Bespoke indicators', below) and changes to how registers function (see 'Register rethink', below), and it is clear that the QOF is changing beyond recognition.

More such innovations may be expected as ministers squeeze even more from GPs, using the ever-controversial QOF.

GP expert view: What it means for daily GP work

Wiltshire GP Dr Gavin Jamie

'These are the biggest changes that we have seen since the introduction of the current contract in 2004. Each of the changes on its own would be significant, but together they are enormous. None of the changes are going to make it easier to deliver care to patients.

'There are indicators set at a 100% upper threshold, and we can expect more of these in 2014/15. It would probably be a mistake to say that GPs won't hit these targets - we have surprised the government in the past. It is not clear how much of this will be down to more achievement or increased exception reporting. Either way is more work for practices.

'In general, practices have gained roughly the same proportion of points from the organisational area as from clinical, so the loss will not be noticed that way. However, it seems expected that most of the organisational (work) will be done anyway, so the resources for that will come out of the global sum pot. New, harder, clinical indicators may mean less money.'

New disease areas
GPs will face fresh clinical challenges in the years ahead, such as the debut of rheumatoid arthritis in April. The four new targets in this disease area include annual reviews and cardiovascular and fracture risk assessments.

The DH is increasingly proposing new QOF indicators to NICE. Given the prime minister's 'Dementia Challenge', it is no surprise that four more dementia targets have been proposed for 2014/15.

Alcohol screening is also on the horizon for April 2014, and new clinical targets for polypharmacy were also considered by NICE advisers in December.

100% thresholds
Arguably the greatest additional workload following the upheaval to QOF will be the controversial changes to thresholds. From April, practices will need to match the 75th centile of national performance to gain maximum points, affecting an initial 20 indicators. Upper thresholds will be set at 100% for indicators CHD14 and HF3, while COPD8, AF3, DM15 and STROKE 12 will be at 97%. If performance rises each year as expected, so will thresholds. Before long, many targets will require 100% achievement to gain full points. The GPC believes this will significantly increase workload and exception reporting.

All-or-nothing targets
NICE advisers recently backed calls from ministers to pool all diabetes targets relating to eight of the nine basic care checks, such as foot checks and HbA1c, into one 'all-or-nothing' target. The resulting, tougher indicator would be vast, worth as much as £10,000 to an average practice. Earning maximum points would rely on hitting all eight targets, possibly at 100% thresholds. Miss one, and a practice could earn nothing for meeting the other targets. NICE is now developing the target for piloting. If approved, it could open the door to further, similar measures in areas where performance is also deemed patchy.

Bespoke indicators
Tightly linked measures (TLMs) form the spearhead of NICE's new direction with the QOF. This new type of target sees GPs aim for different targets depending on how patients respond to treatment. Rachel Foskett-Tharby, a researcher from Birmingham University who works in the team that develops QOF indicators, says TLMs aim to 'bridge the gap' between process and outcome indicators: 'The idea with a TLM is you look for areas where achieving outcomes is beneficial, but also where there are activities practices can undertake that can be linked to the outcome of interest,' she says.

The first TLM developed, for diabetes, attempts to improve cholesterol control for patients with diabetes. It is under consultation and being considered for 2014/15.

The rationale is that cholesterol levels under 4mmol/L are desirable for patients with diabetes. But if a patient cannot reach that level, active management of their cholesterol is recommended nonetheless. The indicator pays GPs to gradually step up treatment by raising the dose or switching onto different types of statin if the 4mmol/L threshold cannot be met. Ms Foskett-Tharby says: 'I think it does recognise that not all patients will reach the outcome (target) and that isn't necessarily due to practices not taking appropriate steps to get them there.'

Register rethink
NICE advisers are seeking to redesign disease registers to improve diagnostic accuracy and ensure lists are kept up to date. This may mean GPs would need to recheck patients' existing diagnoses against defined diagnostic criteria. The indicators could also be time limited to ensure patients are not left on disease registers when they no longer have the condition. These proposals are being examined by NICE.

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