Has QOF proved to be a success?

With NICE poised to redesign the QOF, Sanjay Tanday looks at its record and what could change.

This may be the last year of the quality framework in its current form, with NICE poised to introduce tougher indicators as part of a fundamental overhaul.

Last week saw quality scores rise for practices in England and Scotland for 2007/8 (see graph).

The scores, along with those for Northern Ireland published last month, paint a positive picture of general practice and show that most GPs are meeting their clinical targets. UK-wide, practices now achieve more than 95 per cent of quality points on average.

The quality framework was introduced in April 2004 under the mantra 'delivering substantial financial rewards for high-quality care'.

It has helped GPs to focus on key clinical areas, such as hypertension and chronic kidney disease (CKD), and to identify more disease, as reflected by rising prevalence rates recorded by practices.

'The quality framework means that patients are getting a very high standard of treatment no matter where they live and the gap between those in the most and least deprived areas is narrowing year on year,' said GPC deputy chairman Dr Richard Vautrey.

'Implementing the steps of the framework for CKD can delay progression of the disease.

'Patients with asthma and diabetes are being diagnosed promptly, getting early treatment and this is making a real difference by improving quality of life, reducing hospital admissions and saving lives.'

QOF benefits
West London GP Dr Sarah Jarvis added: 'The framework has brought up the standards of care and helped to reduce inequalities across the UK.'

The biggest impact has probably been seen in the care of patients with cardiovascular disease (CVD) and diabetes, where there is the most evidence for treatment, said Dr Jarvis.

A DoH report, published in August, found that not only had the number of people receiving diabetes tests increased each year since the quality framework was introduced, but outcomes had also improved.

Around 2,000 sufferers have been identified every week since tests for diabetes were introduced into the quality framework, the report found.

But as GPs across the UK celebrate this year's scores and the impressive impact on patient health, the prospect of a tougher framework looms.

In July, Lord Ara Darzi told the House of Commons health select committee that in future NICE, rather than the expert review panel, would identify priorities for the framework.

Cost-effectiveness and impact on the 'health of the nation' would be the deciding factors, with interventions scoring high on both most likely to be included, he told MPs.

The shake-up would see some current indicators dropped, Lord Darzi told MPs. 'I can't believe it's going to be extra points in the QOF,' he said.

Professor Martin Roland, one of the architects of the quality framework and director of the National Primary Care Research and Development Centre in Manchester, said that it was always expected that the framework would evolve.

'There has already been a progressive change. New indicators and thresholds have been introduced. But NICE will need to take on board advice when developing the framework.'

Asked whether NICE would create a tougher framework more focused on cost-effectiveness than clinical care, Professor Roland said he expected new indicators to reflect the institute's guidance.

'GPs are mindful of cost, so they are already concerned about the cost-effectiveness of indicators,' he added.

Harder targets
Dr Jarvis warned: 'If the government has anything to do with the quality framework then it is bound to become harder to achieve points.

'The government has been trying to claw back more from the framework because GPs have been over-performing.'

NICE has also been in discussions with the DoH over plans for a locally determined quality framework (Plan for local QOFs raises postcode lottery fears, GP, 10 September).

Indicators could be selected from a 'national menu', an idea first floated by Professor Roland. 'A degree of local variation would be fine provided the local indicators can be drawn from a menu,' he said.

But PCTs should not be developing their own indicators, because of the complexity of the task, he warned.

Some obesity experts, concerned that the current quality framework is failing to tackle rising levels of obesity, have backed local indicators.

Currently, GPs earn eight points simply for taking a register of obese patients.

'The current obesity indicator is of no clinical benefit at all,' according to Dr David Haslam, clinical director of the National Obesity Forum.

Dr Colin Waine, the forum's chairman, said local indicators would allow a targeted approach. 'We know where obesity prevalence is high.'

NICE is expected to announce details of quality framework changes in the coming months. Many GPs will hope for evolution rather than revolution.


Expert View

  • "You would expect NICE to develop framework indicators that do not go against their own guidance." - Professor Martin Roland, director, National Primary Care Research and Development Centre
  • "The framework has brought up the standards of care and reduced inequalities across the UK.The biggest impact has probably been for patients with cardiovascular disease and diabetes, where there is the most evidence for treatment." - Dr Sarah Jarvis, GP, west London
  • "We know where obesity prevalence is high. In principle if you have a disease in a particular area that is high, some sort of local QOF flexibility is a good thing." Dr Colin Waine, chairman, National Obesity Forum

QOF Facts

  • Practices have increased the proportion of quality points they earn since the system was introduced in 2004/5.
  • Scores flatlined between 2005/6 and 2006/7 after targets were revised. The number of points on offer fell from 1,050 to 1,000 as 50 points were redirected to pay for access.
  • The average practice earned £116,160 from the quality framework in 2007/8.
  • A total of 655 QOF points are for clinical work, divided into 80 indicators across 19 clinical areas.

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