Impact of prevalence change

QOF changes will bring large swings in income for some practices, writes Stephen Robinson.

All practices' incomes will be hit by the latest changes to QOF pay.

There are likely to be more winners than losers, and some practices could see income from QOF grow by up to 39 per cent. But others stand to lose six-figure sums.

Yet a quarter of PCTs are still to assess the impact on practices - a significant concern considering the repeated calls from the DoH, LMCs and the RCGP to act.

So why is the change being made, and how will it impact on practices?

The nuts and bolts
The way QOF payments are calculated has changed.

Before 1 April 2009, each practice had a prevalence 'factor' calculated for each disease area.

Practices with disease prevalence in the bottom 5 per cent of the range in each UK country would be rounded up to that mark, and values square rooted to reduce outliers.

The final value was used to weight QOF pay per point for each disease area.

For example, a practice achieving a 50 per cent greater adjusted prevalence for a particular disease than the national mean had a prevalence 'factor' of 1.5, so it received £187.50 per point for this disease area, rather than the basic £125.

The system was heavily criticised for failing to fully recognise the workload of practices with the most ill patients.

Also, even with square rooting, non-standard practices with extremely high disease prevalence skewed payments for whole domains, leaving nearly all practices in the country with the same prevalence factor for some disease areas.

Now, these adjustments have been swept away, leaving true prevalence to weight QOF income.

GPC chairman Dr Laurence Buckman says the changes are fairer because more money will go to GPs with large numbers of chronic disease patients.

PCTs are unprepared
But a GP investigation shows that, by the end of March, 25 per cent of 103 PCTs had still not assessed the impact the change would have on practices.

The DoH insists that PCTs ought to have carried out the assessment already. A spokesman said: 'The DoH made it clear through advice given to SHAs' directors of commissioning that PCTs should work with those practices most affected by the changes.' It advises PCTs to examine if local enhanced services (LESs) are needed where income is lost due to genuinely low prevalence.

University practices will be worst hit by the changes, because of their low prevalence in areas covered by the QOF.

Dr Irene Weinreb, a GP at Imperial College Health Centre in London, says PCTs' support for university practices needed to match the demands placed on them.

She argues: 'You cannot encourage 50 per cent (of young people) to attend university then not support those practices.'

Some PCTs told GP they will make additional investment in enhanced services to compensate for QOF losses. NHS Croydon has allocated an extra 60 points for LESs in a local QOF scheme it operates, NHS Southampton City is proposing a sexual health LES, and NHS Westminster has invited practices to bid for LESs under its 'Innovation Health Scheme'.

But PCTs where practices gain from QOF changes may cut other services. NHS Bournemouth and Poole says: 'The PCT is already facing financial constraints and this is another issue to be addressed. A number of LESs may be withdrawn alongside other cost saving measures.'

QOF loser - university practice

Dr Hugh Porter is a GP at Cripps Medical Centre at Nottingham University, one of the largest university practices in the country. He says removing the square root component of the prevalence formula was justified, but that dropping the uplift component was not.

He says: 'It always seemed fair to remove the square root so as to correctly reward those practices with above average prevalence, but the removing of the 5 per cent cut off is more contentious.'

The GPC had originally said the uplift was put in place to cover the cost and effort to run QOF, even in disease areas where the practice list had low prevalence.

Dr Porter says: 'This need and effort hasn't changed, and so it seems less obvious why it was discarded.'

The removal of the uplift will mean practices like Cripps Medical Centre will see payment per QOF point plummet, and make pursuing these QOF targets less efficient.


QOF winner - high prevalence practice

County Durham GP Dr Stewart Findlay believes the system is fairer now. 'It's not contentious at all,' he says, adding that those working in the most deprived areas with high disease prevalence are doing 'considerably more work' than those in the 'leafy suburbs'.

He says the changes to QOF prevalence are likely to benefit his practice, which has high prevalence of diseases such as diabetes and CHD. 'The idea behind the new contract was that practices would be rewarded for doing more work. If we've got twice as many patients with chronic diseases, we should get twice the pay.'


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