QOF: Off the menu

With latest suggested indicators announced, which – if any – will be implemented? 

For the last three years, a committee at the National Institute for Health and Care Excellence (NICE) has produced a selection of suggested new indicators annually for the quality and outcomes framework (QOF). Although the menu is produced in the summer, it could be well into 2014 before we know which indicators will become part of the QOF. Historically the take-up of new indicators has been variable. 

In the first year that NICE proposed new indicators around half were taken forward; in 2013 almost all of the indicators were incorporated into the QOF. The final line-up is decided by NHS Employers or local devolved administrations. Normally this is after negotiation with the General Practitioners Committee (GPC), although this year in England there was a unilateral imposition. It is also during this process of negotiation that the achievement thresholds and points values of the indicators are set.

We already know that the payment thresholds for most existing indicators are likely to rise next year, although the amounts will vary across the UK. 

All of this is subject to change. There is always the chance that, as the general medical services (GMS) contract is renegotiated, there will be no QOF at all next year. Equally, indicators that are not included in the menu may be included. This is particularly likely in the organisational and public health domains, such as the quality and productivity (QP) indicators.

The ‘menu’ of indicators has become more conservative in each successive year. Reading through the minutes of the committee there is a distinct feeling that they are drawing from a well that is rapidly drying up. There are no new disease areas and few new actions required of practices in the currently proposed indicators. While there are difficulties with some of the indicators it seems quite possible that the menu could be implemented in its entirety, subject to enough points being available.

In previous years there were a number of indicators suggested for removal, or retirement, from the QOF. These were no longer relevant or considered to be embedded into practice and did not require further incentives. This year no indicators are suggested for removal. New indicators may be funded by trimming points from other indicators or the negotiated removal of indicators. The GPC has stated that it hopes to negotiate the removal of the General Practice Physical Activity Questionnaire in this round.

In the current QOF (2013/14), achievement indicators in the hypertension area were split with a higher achievement threshold of 150/90 in all patients, and a separate indicator with lower threshold of 140/90 which attracted the bulk of the points for patients under 80 years old at the end of the QOF year. There were concerns raised at the time by the GPC that a stricter target may increase the risk of hypotensive side effects as patients are treated more intensively. There has not really been enough time to find out if this has been seen in practice, but it is proposed to extend these lower thresholds into three other disease areas.

Stroke, coronary heart disease and peripheral vascular disease all have proposed indicators with a lower blood pressure target of 140/90 in patients 79 years or younger at the end of the QOF year. Diabetes has already had split targets for the last few years, although patients are not divided by age.

As the principle has been demonstrated this year, it seems quite likely that these indicators will pass through the negotiations unchanged. They may not even need any extra points. When the hypertension indicators were split, so were the points. Despite the increase in work there was no increase in the reward.

A more novel potential indicator concerns the provision of contraception or pregnancy advice to female patients with diabetes who are aged between 17 and 45. Pregnancy carries higher risks for both mothers and babies in diabetes. NICE quotes a five-fold risk of stillbirth and a trebling of congenital abnormalities. Good blood sugar control before conception can significantly improve outcomes. Pregnancies should be carefully planned.

The indicator is currently framed that there should be a record of advice, either pregnancy or contraceptive related. An alternative to this may be a recorded prescription for contraceptives. Where a form of long-acting contraceptive, such as intrauterine device or hormone implant, is used it is likely that an advice code would be required annually. This should generally be given face-to-face.

There has been a similar indicator for women who are receiving treatment for epilepsy for the last couple of years. This required separate codes for contraception, pre-conceptual and pregnancy advice and applied to women up to the age of 55. 

It is proposed that this be modified in the same way as the diabetes indicator. The criteria would be simplified and the upper age limit brought down from 55 to 45. Ticking the boxes for conception advice in women several years past their menopause has been a little bizarre for the last couple of years and this has now been acknowledged.

The change to the epilepsy indicator will just be a tweak to the description but the diabetes indicator will require some points to be found from somewhere.

Dementia has been in the QOF for some time but in the last year the incentives have mostly been part of a directed enhanced service (DES). This specifically rewarded a screening type programme for dementia but also specified the use of dementia specialist services for diagnosis and the identification of the carers of patients with dementia.

The proposed indicators represent an attempt to bring these back into the QOF. They would most likely replace the DES requirements and specify their own targets for the diagnosis and management of dementia.

The underlying process is similar in both the DES and the proposed new QOF indicators. The initial assessment for memory problems would take place in general practice as well as initial blood tests to look for any possible causes of a pseudo-dementia. Further assessment and a definitive diagnosis would take place in a specialist memory service.

While the current DES largely rewards screening the indicators, QOF will concentrate more on the process of diagnosis. The current indicator for a bank of blood tests has a timescale of six months before or after the date of diagnosis. This will be changed to within the 12 months before the diagnosis is made. The tests remain the same and would generally be expected to be taken around the time of referral.

The second proposed indicator requires that patients should have attended a memory assessment service, also in the 12 months prior to diagnosis. Diagnosis in primary care is expressly discouraged, a situation that the NICE advisory committee was aware of. In cases where it is justified then these patients will need to be exception reported. These exception rates are as likely to come under scrutiny as in other indicators. This is likely to put additional pressure on specialist memory services.

The third indicator requires that a named carer is identified for each patient with dementia and that the contact details are recorded in the surgery. This is already included in the DES although moving it to a target adds some complication. Patients may not need to have a carer in the early stages of the disease and so there may be nothing to record. In this case exception reporting is likely to apply.

In other cases patients have professional carers, either in a residential home or through social services in their own home. As the indicator requires a named carer it is uncertain how this would apply to professional services. More guidance who is considered to be a carer will be required if the indicator is to be implemented.

The current indicator requiring a general annual review in patients with dementia is expected to remain.

Perhaps the biggest single indicator suggested is a change to how hypertension is diagnosed. In the past this has been by a series of blood pressure measurements in clinic. NICE changed its guidance a couple of years ago so that the recommended method of diagnosis is now by ambulatory blood pressure monitor. This guidance has now moved along the pipeline to appear as a QOF indicator proposal.

The recommendation is that, after a clinic measurement of 140/90 or more, patients should have an ambulatory pressure measurement. Readings should be taken twice in each waking hour and the diagnosis only made if the average reading is 135/85 or over.

An alternative method of measuring blood pressure outside the surgery would be through the use of home blood pressure measurement. This would require two readings twice daily for between four and seven days, although the first and last days’ readings should be discarded.

The choice is up to the practice, but the capital equipment cost for a home blood pressure meter is substantially less than for an ambulatory machine. This would be balanced by the increased time of use to make a diagnosis and may be more useful in smaller practices.

Capital investment and the time taken to make a diagnosis will be factors that influence practice take up of this indicator. Like most QOF indicators payment will likely only start at 40% achievement and so partial engagement is not really an option.

Around a quarter of a million people were diagnosed with hypertension in England in the QOF year 2011-12, out of a population of 55 million. This represents around 31 patients for an “average” practice. It is suspected that up to a fifth of these may have been diagnosed in error. While the thresholds and the points available will be decided at the time of negotiation NICE have given some indications. The thresholds are suggested to be from 40-90% with around 23 points available, although where they would come from is not suggested.

A very rough calculation suggests that a practice who achieved the upper threshold would earn around £100 for each patient tested. This may be less if there is an increase in more speculative testing and will be a little more per diagnosis made, as some of the ambulatory tests will be negative.

Practices will need to consider the cost of an appointment to attach the machine and instruct the patient and a further appointment to remove it and analyse the results. Capital costs and later repair and replacement will also need to be considered. There is also a minor perverse incentive as reduced rates of diagnosis will reduce prevalence and the value of points to a practice.

There are many possible changes to the GP contract next year. Almost anything is possible. It is perhaps only a small reassurance to practices that changes in the content of indicators seems likely to be fairly small. There may be further differences across the UK. We will have to wait and see.