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Final score

Final score
8 February 2013

General practices are keeping a close eye on their progress towards this year’s quality and outcomes framework (QOF). There is a lot of work to do before the calculation day at the end of March. At the same time there is real uncertainty about what next year will bring. It is not even clear when practices should start preparing for next year’s requirements.

General practices are keeping a close eye on their progress towards this year’s quality and outcomes framework (QOF). There is a lot of work to do before the calculation day at the end of March. At the same time there is real uncertainty about what next year will bring. It is not even clear when practices should start preparing for next year’s requirements.

In the midst of this work and speculation, the data for last year (2011-12) has been released. This is a good time to look back and see which direction things are heading. There is extra significance to the results this year as they may well have a direct influence on the indicators and thresholds in the future.

The headline figure is that the average number of points gained has increased since the previous year. More practices have also earned all of the available 1,000 points. Looking more closely this seems to be only in a very small part due to increases in the proportion of points achieved in the clinical domain and mostly due to gains in the organisational domain. There were actually fewer points available for clinical activity in 2011-12 as some were moved to organisational indicators.

This was the first year of the Quality and Productivity (QP) indicators, which mostly inherited their points from the results of the national patient survey. The survey had awarded points on a sliding scale and it was rare for practices to get them all. Most of the QP indicators were “all or nothing” based on paperwork returns to the primary care trust (PCT) and practices have been rather more successful in earning the points. This trend may well continue in 2012-13 as the sliding scale prescribing indicators have been replaced with more paperwork submissions.

The QP indicators are also the only organisational indicators that the government says it wishes to continue into 2013-14. The achievement of these indicators seems to be similar to general achievement across both the clinical and organisational domains at around 97%.

Disease prevalence is crucial to practices. It affects the value of the points in that area. Each point is adjusted according to the ratio of disease prevalence in the practice to the national prevalence, calculated separately in each of the four nations. There is a maximum amount of cash allocated for each disease area that is split between all of the patients on that disease register.  The effect of this is that a higher practice prevalence will increase practice income but an increasing national prevalence will reduce the payment for each patient with the diagnosis.
Trends in prevalence have continued pretty much as they have since the start of the QOF. Every year there have been 100,000 more patients with a diagnosis of diabetes, increasing the prevalence rate by about around 0.2%. This is annually diluting the payment for each of these patients.

There are increases also in hypertension. The rate of increase has been tailing off but almost one in seven people in the UK now carry that diagnosis. There was a small reduction in the number of points in this area as well, further reducing the payment for each patient.

Both thyroid disease and COPD have also risen every year that they have been part of QOF. This may be due to an increase in the awareness of the diagnosis.
In the case of COPD, there are acknowledged to be significant numbers of patients who have not received a diagnosis. This is less true of hypothyroidism and may be at least partly due to improved coding.

The rate of increase in dementia seems actually be to be increasing from quite a small level. This may reflect increased attention on this condition and could well increase over the next couple of years as the NHS is mandated to become more focused on dementia.

There were slow rises in mental health, learning disabilities, stroke and atrial fibrillation.

Although it is not a true indicator of prevalence, the obesity register (body mass index of over 30 recorded in the past year) continues to race ahead and looks set to rise above 9% of the total population in 2013.

After all of the attention paid to smoking cessation and the control of cholesterol and blood pressure levels, it is good news that the register of patients with coronary heart disease has been falling. Although this is not an absolute measure of the number of new heart attacks or angina, it does suggest that we are achieving better heart health.

Achievement in each of the indicators takes on a new importance this year after the governments of England, Wales and Northern Ireland have signalled their intention to change the upper threshold for the clinical indicators to the previous upper quartile of achievement over the next two years. This means that by 2014-15, the upper threshold will be set at the levels of the top quarter of practices this year.

It is not clear what plans the Scottish government has for the indicator thresholds. It is also not clear if the other countries intend to calculate their own thresholds or to set them on a UK basis.

The plan is to move towards these levels over two years. The thresholds for 20 indicators will rise in 2013/14 with the remainder rising in the following year. Rises will then be annual.

It is not clear what the effect of raising thresholds is on the level of achievement. General practice has shown many times over the years, not least at the introduction of the QOF, an ability to rise to a challenge. There is likely to be some effect on absolute achievement as well as an increase in exception reporting. As thresholds have risen this year (2012-13), it is likely that the upper quartile will also rise. The figures for chronic kidney disease (CKD) have the smallest apparent rise in the table. This is an area that had an upper threshold of 70% in 2011-12 but 80% this year and the achievement is correspondingly lower.
The quartiles are split by county. On a UK-wide basis the figures would be very similar to the English levels as the large majority of practices are in already represented by the English data.

The differences between the upper quartiles for each country are not dramatic. Payments for each patient already differ where prevalence calculations are made separately. Threshold changes will simply make the gap wider.

There are no cases where the threshold is likely to fall. As we have already seen, practices have been getting high point scores by surpassing the current targets.
Indicators with relatively small numbers of patients, such as those related to the measurement of lithium levels, epilepsy or heart failure, could have their upper threshold raised to 100% – all patients will need achievement or exception codes recorded in those cases.

Extreme though these are, it is likely to be areas with larger numbers of patients that will be more of a challenge to practices. If the number of points remain the same, and there is no assurance that this will be the case, raising the threshold will dilute the payment for each patient who hits the target.

There are large rises in outcome indicators for patients with diabetes. In the tightest glucose control indicator, getting HbA1c below 59mmol/L (7.5% in old money) the threshold could rise from 50% to 75% percent. The middle indicator would rise by 13%. There would only be a 2% rise in the threshold for the highest indicator, which is already at 90%. The higher blood pressure target would rise by more than 20%.

The story is similar in most of the other indicators. The blood pressure targets in both CHD and stroke are likely to rise close to 20% as well. Cholesterol target indicators show the same sort of increases in these areas.

Influenza vaccination quartile levels are around 95% in all areas. Current upper thresholds are between 85% and 90%.

It can be easy to forget these are results that should be a source of pride to general practice. We are seeing patients treated to a high level of care and that care seems largely to be unconstrained by QOF thresholds. In most cases practices are working significantly above these thresholds. The QOF seems to be incentivising the setting up of practice systems that are working well even at levels where the incentive has ceased. There is no other primary care system in the world that can demonstrate this sort of data about the management of chronic disease.

It is a pity that higher levels of achievement may be seen as a risk to practices from a change in thresholds. It is also not known what the effect of these increases will be – an increase in achievement or just in exception reporting?

Exception reporting information has also been published. The overall rates of exception reporting are pretty much unchanged since last year. Indicators which were new for this year have had the highest level of exception reporting.

Two of the new areas were ‘bundles’: chronic heart disease (CHD) 14 required prescription of four separate drugs in patients with a new diagnosis of myocardial infarction and DEM 3 required a suite of blood tests in patients with a new diagnosis of dementia. In both cases, if a patient was excepted from one or more prescription or test, and achieved the others, they were excepted from the whole indicator.

The dementia indicator had the highest exceptions in England with more than 40% of patients exception reported. This will include automatic exceptions for new patients or those with a new diagnosis. The CHD indicator had the fifth highest exception rate at nearly a quarter of patients.

This is likely to need consideration before other bundled indicators are included – although there are not currently any plans for the next year.

The newer indicators dominated the top ten exception reporting list although this may be at least partly down to newer indicators tending to be more outcome based. As always there have been higher exception reporting rates in outcome indicators, where a specific patient outcome must be met, than in the indicators which simply record that a process has taken place.

This is yet another year of solid results with practices achieving highly. It marks the final year of a fairly quiet period in QOF development. There had been no change at all in the previous year. The productivity indicators were the main radical change – the clinical changes were relatively modest. With stability comes the ability to compare one year with the last one and clinical quality appears to be holding steady. Looking to the future however we have to ask, is it steady enough?

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