QUALITY & OUTCOMES
FRAMEWORK
Philip Leech
Key points
• The QOF is voluntary - but practices that don’t
take part are likely to rely on the MPIG
• PMS practices can opt out of the national QOF but agreeing local variations will be hard work
• Non-computerised practices will be at a distinct
disadvantage
• Day-to-day delivery of the QOF will fall more on
practice nurses and practice managers than on GPs
Contents of QOF Guidance
Activities and milestones for 2004/5
Preparatory funding
Aspiration calculation and payment
Prevalence
Annual quality visits
Calculation of achievement points and payment
Ensuring equity and probity
IM&T and data flows
QOF review and adaptation
QOF Improvement Cycle
Planning
Learning
QOF
IMPROVEMENT
CYCLE
Review
Action
QOF Activities for 2004/5
Feb 2004
Agree
aspiration
April 2005
Achievement
payments made
Apr 2004
Pay QPrep and
QuIP DES
Oct 04 – Jan 05
Annual review
visits take place
August 2004
QMAS system goes
live & provides
monthly feedback
QOF
2004/5
End April 2004
Monthly
aspiration
payments
April 2004
QOF goes live
April 2004
DH guidance
on review
visits
Structure of the QOF - 1
• Clinical domain
- 76 indicators
- 10 disease areas (CHD, stroke/ TIA, cancer,
hypothryroidism, diabetes, hypertension, mental health,
asthma, COPD and epilepsy)
- 550 points
• Organisational domain
- 56 indicators
- 5 areas (records, information, patient communication,
education and training, practice management and
medicines management)
- 184 points
Structure of the QOF - 2
• Patient experience domain
- 4 indicators
- 2 areas (patient survey and consultation length)
- 100 points
• Additional services domain
- 10 indicators
- 4 areas (cervical screening, child health surveillance,
maternity services and contraceptive services)
- 36 points
Structure of the QOF - 3
• Holistic care payments
- based on points scored in clinical domain
- 100 points
• Quality practice payments
- based on points scored in organisational, patient
experience and additional services domains
- 30 points
• Access bonus
- based on achievement of 24/ 48 hour access target
- 50 points
Preparatory funding
• Quality Preparation Payments (QPrep)
– Nov 2003: all receive payment (£9000 for practice with
average list size)
– end Apr 2004: second payment (£3250 for average practice)
for practices participating in QOF
• Quality Information Preparation (QuIP) DES
– to help practices summarise records, depending on list size
and amount of work
– PCTs offer 2004 QuIP to practices by 1 Jan 2004
– for 2005, schemes agreed before 1 Apr 2004 are paid to
practices with next monthly payment
Aspiration Payments
• Arrangements for 2004/5
– practice and PCT agree aspiration points total
– practice paid a third of this
– not weighted by prevalence but weighted by relative
list size
• Arrangements for 2005/6
– practice paid on the basis of 60% of its achievement
payment for the previous year
– weighted by prevalence and relative list size
• Aspiration payments paid monthly
Prevalence adjustment
• Only applies to practices doing national QOF
• Acknowledges that practices with low prevalence
still have costs in setting up registers and regularly
checking patients.
• Provides adequate income protection to practices
with lowest prevalence
• Delivers appropriate rewards to practices with
highest prevalence (no cap!)
How does it work?
• Prevalence adjustment is based on the contractor’s
prevalence measured against the national average
• Contractor’s prevalence = no of patients on disease
register
• Separate calculation made for each disease area
• Adjusts the pounds per point available for each
disease area
0
£ 1 4 0 -£ 1 4 5
£ 1 3 5 -£ 1 4 0
10
£ 1 3 0 -£ 1 3 5
£ 1 2 5 -£ 1 3 0
£ 1 2 0 -£ 1 2 5
£ 1 1 5 -£ 1 2 0
£ 1 1 0 -£ 1 1 5
£ 1 0 5 -£ 1 1 0
£ 1 0 0 -£ 1 0 5
£ 9 5 -£ 1 0 0
£ 9 0 -£ 9 5
£ 8 5 -£ 9 0
£ 8 0 -£ 8 5
£ 7 5 -£ 8 0
£ 7 0 -£ 7 5
£ 6 5 -£ 7 0
£ 6 0 -£ 6 5
£ 5 5 -£ 6 0
£ 5 0 -£ 5 5
£ 4 5 -£ 5 0
£ 4 0 -£ 4 5
£ 3 5 -£ 4 0
£ 3 0 -£ 3 5
£ 2 5 -£ 3 0
£ 2 0 -£ 2 5
£ 1 5 -£ 2 0
45
£ 1 0 -£ 1 5
£ 5 -£ 1 0
u p to £ 5
fr e que nc y
CHD
Distribution of £s per point, under raw and adjusted prevalence rates
- CHD
40
35
30
25
20
15
Raw
Adjusted
5
Additional Services Adjustment
• Pounds per point adjusted by relative size of target
population
• Protects contractors with large target populations
• Rewards for greater workload
• Relative size of contractor’s target population is
compared to national average
Target Populations
Cervical
screening
Cervical
Screening
WomenWomen
aged 25 toaged
64 years
25
to 64 years
Child
surveillance
Children
aged under
5 years
Children
aged
under
Childhealth
health
surveillance
5 years
WomenWomen
aged under
55 years
aged
under
55 years
aged
under
Contraceptive
services
WomenWomen
aged under
55 years
Contraceptive
Services
55 years
Maternity
services
Maternity
Services
Don’t panic!
• For the national QOF, these calculations will be
made automatically by the IMT software (Quality
and Outcomes Framework Management &
Analysis System aka QMAS)
• PCTs of PMS practices taking part in a locally
agreed QOF will need to do their own calculations
Annual Review
• Commissioned the School of Health and Related Research
(ScHARR) to develop proposals
• Separate guidance will be published in April 2004 by DH
• Current guidance sets out key principles
• Visits should take place between October and January PCT should agree and publish a schedule
Supporting Information
• Supporting information to be submitted by contractor one
month before the visit
• Required information set out in New GMS Contract 2003:
Supplementary Guidance
• Must cover all areas for which the contractor intends to
submit an achievement claim
• Will certainly include levels of exception reporting and any
anomalous data eg on referrals
Annual Review Assessors
• Selected on the basis of meeting certain
competencies
• Appropriately trained - national training available for
a limited number of assessors
• One assessor will normally be a doctor (or another
healthcare professional by agreement between
practice and PCT)
• One assessor will normally be a lay person
• Bound by a code of practice on confidentiality
• Visit may involve LMC
Outcomes of the Visit
• Assessment of contractor’s likely achievement
against the QOF
• Written report, seen in draft by the practice
• Remedial plan if visit highlights issues around data
quality eg Read coding
• Remedial plan to be implemented by contractor
within one month of agreement
Annual Review Visit
DO
• Identify the person responsible for visits
• Start working on a visit schedule now
• Identify potential assessors, and check availability
• Wait for publication of national guidance in April
before working on the detail
Annual Review Visit
DON’T
• Get too bogged down in detail: further guidance
will be published in April
• Assume national training will be available for ALL
your assessors
• Ignore everything until April!
Ensuring Equity & Probity
• PCT verification of achievement claims before payment
• PCTs can re-score contractors’ achievement claims, in
some circumstances
• Remedial action on data quality if annual review visit
generates concerns
• Random 5% check of achievement claims to deter fraud
IM&T and Data Flows
• Practices do not need new software, just an RFA99
compliant clinical system
• Reports from QMAS - monthly to PCTs, at least monthly to
practices
• QMAS reports will, in time, have comparative data on
achievement and trends (local and national)
• Consultation on impact of Freedom of Information Act (kicks
in January 2005)
GP Practice
GP Clinical
System
Clinical System
Achievement Data
(IT Interface)
PC
Other
Achievement
Data
(Web)
Achievement Reports
(Web)
Payments
(BACS)
PCT Payment Agency
Centralised IM&T
Agreed
Achievement
(IT Interface)
Management and Analysis
System (MAS)
Achievement Reports
(Web)
PCT
PC
NHAIS
Review of QOF
• Process for reviewing QOF will be established this
year
• Will be informed by PMS local QOF experience
• Major changes unlikely before April 2006
• Smaller changes before then to remove errors and
take into account groundbreaking new evidence
To sum up...
• The IMT will do all the calculations for you
• You need to focus on:
- appointing a QOF lead for your PCT
- agreeing aspirations (if you haven’t already)
- encouraging practices to get ready for the IMT (Read
codes, list cleaning, computerisation)
- identifying potential assessors
- booking annual review visits
• You are part of a world first!
Getting more information
• GMS and PMS:
helpline - 0845 900 0008
inbox - [email protected]
website - www.natpact.nhs.uk/primarycarecontracting/
• QOF guidance:
GMS www.doh.gov.uk/gmscontract/implementation.htm
PMS www.doh.gov.uk/pmsdevelopment/
pmsarrangementsdec03.pdf