Quality and Outcomes Framework
Encyclopedia
The Quality and Outcomes Framework (QOF) is a system for the performance management and payment of general practitioner
s (GPs) in the National Health Service
(NHS) in England
, Wales
, Scotland
and Northern Ireland. It was introduced as part of the new general medical services
(GMS) contract in April 2004, replacing various other fee arrangements.
In the 2004 contract the practice could accumulate up to 1050 'QOF points' (depending on level of achievement for each of the 146 indicators. The criteria are grouped into 4 domains: clinical, organisational, patient experience and additional services. The criteria are designed around best practice and have a number of points allocated for achievement. At the end of the financial year the total number of points achieved by a surgery is collated by the QMAS or other system which then converts the points total into a payment amount for the surgery. The formula includes the number of patients and in particular the numbers diagnosed with certain common chronic illnesses; the clinical element awards points for achieving specified clinical "indicators".
A typical clinical indicator would be the proportion of patients with coronary heart disease
who had cholesterol measured in the financial year, or the number of patients with depression who have answered a standard questionnaire on severity. Organisational indicators include such things as the availability of practice leaflets, and practice staff education.
In the organisational domain the value of points was proportional to the number of patients registered with the practice. In the clinical domain the value of points was further modified by the prevalence of that condition in the practice - this was measured as the square root of the ratio of the national prevalence. For a typical practice the payment was £77.50 per point in 2004/5 and £124.60 in subsequent years.
The QOF system is supervised and audited by NHS primary care trust
s in England and the analogous bodies elsewhere in the UK (Health Boards in Scotland, Regional Boards in Northern Ireland, and Local Health Boards in Wales), who make the related payments.
, heart failure, stroke
and transient ischaemic attacks, hypertension
, diabetes mellitus
, chronic obstructive pulmonary disease
, epilepsy
, hypothyroidism
, cancer
, palliative care
, mental health
, asthma
.
Added in 2006 were dementia
, depression
, chronic kidney disease, atrial fibrillation
, obesity
, learning disabilities, smoking
.
QOF version 10 was introduced in July/August 2007, mainly minor changes to the system, removing, adding or changing codes in the clinical areas to bring them in line with current guidance or to fix typos.
Further changes to the QOF for 2008 include the addition of new indicators for COPD
and smoking cessation
. Points have been removed from the access and patient experience domains.
Practices in Scotland have been found to use exception reporting appropriately in that patients who were older or who had dementia were more likely to have been "exception reported". However, younger or more socio-economically deprived patients were more likely to be recorded as having refused to attend for review or not replying to letters asking for attendance at primary care clinics. It has therefore been highlighted that primary care practices should identify and monitor these individuals (i.e. the youngest and most deprived with cardiovascular disease) so that all patients fully benefit from the implementation of the new GMS contract and receive appropriate clinical care to prevent further disability and mortality.
Tim Burr, head of the NAO, said in 2008: “There is no doubt that a new contract was needed and there are now 4,000 more GPs than five years ago. But in return for higher pay, we have yet to see real increases in productivity.”
However, substantial improvements have been noted, particularly in the maintenance of disease registries and screening of risk factors for older patients with cardiovascular disease in the community.
Ben Bradshaw, the Health Minister said: “The GP contract... has stemmed the haemorrhaging of GPs from the NHS and improved the quality of care for the public. Longer consultations, quicker appointments and being able to book ahead are improvements valued by patients.”
Laurence Buckman, chairman of the BMA’s GP committee, said “The early evidence is that the contract is leading to improvements in clinical care".
General practitioner
A general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...
s (GPs) in the National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
(NHS) in England
England
England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...
, Wales
Wales
Wales is a country that is part of the United Kingdom and the island of Great Britain, bordered by England to its east and the Atlantic Ocean and Irish Sea to its west. It has a population of three million, and a total area of 20,779 km²...
, Scotland
Scotland
Scotland is a country that is part of the United Kingdom. Occupying the northern third of the island of Great Britain, it shares a border with England to the south and is bounded by the North Sea to the east, the Atlantic Ocean to the north and west, and the North Channel and Irish Sea to the...
and Northern Ireland. It was introduced as part of the new general medical services
General medical services
General medical services is the name used in the United Kingdom to describe the medical services provided by General Practitioners who, in effect, run private businesses independently contracting with the National Health Service...
(GMS) contract in April 2004, replacing various other fee arrangements.
Aims and mechanisms
The QOF was of revised contract for GPs. It was intended to improve the quality of general practice and was part of an effort to solve a shortage of GPs. The QOF rewards GPs for implementing "good practice" in their surgeries. Participation in the QOF is voluntary for each partnership, but for most GPs, under the present contract, the QOF is almost the only area where they can make a difference to their income. Almost all participated. Most practices got, and still get, a significant proportion of their income through the QOF.In the 2004 contract the practice could accumulate up to 1050 'QOF points' (depending on level of achievement for each of the 146 indicators. The criteria are grouped into 4 domains: clinical, organisational, patient experience and additional services. The criteria are designed around best practice and have a number of points allocated for achievement. At the end of the financial year the total number of points achieved by a surgery is collated by the QMAS or other system which then converts the points total into a payment amount for the surgery. The formula includes the number of patients and in particular the numbers diagnosed with certain common chronic illnesses; the clinical element awards points for achieving specified clinical "indicators".
A typical clinical indicator would be the proportion of patients with coronary heart disease
Coronary heart disease
Coronary artery disease is the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries that supply the myocardium with oxygen and nutrients. It is sometimes also called coronary heart disease...
who had cholesterol measured in the financial year, or the number of patients with depression who have answered a standard questionnaire on severity. Organisational indicators include such things as the availability of practice leaflets, and practice staff education.
In the organisational domain the value of points was proportional to the number of patients registered with the practice. In the clinical domain the value of points was further modified by the prevalence of that condition in the practice - this was measured as the square root of the ratio of the national prevalence. For a typical practice the payment was £77.50 per point in 2004/5 and £124.60 in subsequent years.
The QOF system is supervised and audited by NHS primary care trust
NHS Primary Care Trust
An NHS primary care trust is a type of NHS trust, part of the National Health Service in England. PCTs commission primary, community and secondary care from providers. Until 31 may2011 they also provided community services directly. Collectively PCT are responsible for spending around 80% of the...
s in England and the analogous bodies elsewhere in the UK (Health Boards in Scotland, Regional Boards in Northern Ireland, and Local Health Boards in Wales), who make the related payments.
Changes in 2006
The GMS contract was revised in April 2006 and, in particular, the QOF was adjusted. The clinical domain was extended from 11 to 18 areas and 138 points were reassigned. The total number of points was reduced to 1000 and the 50 points that were previously attainable through as "access points" are now folded into an "access" Directed Enhanced Service (DES)http://www.nhsemployers.org/primary/primary-893.cfm. The clinical areas now include coronary heart diseaseCoronary heart disease
Coronary artery disease is the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries that supply the myocardium with oxygen and nutrients. It is sometimes also called coronary heart disease...
, heart failure, stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
and transient ischaemic attacks, hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
, diabetes mellitus
Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
, chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease , also known as chronic obstructive lung disease , chronic obstructive airway disease , chronic airflow limitation and chronic obstructive respiratory disease , is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases...
, epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
, hypothyroidism
Hypothyroidism
Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone.Iodine deficiency is the most common cause of hypothyroidism worldwide but it can be caused by other causes such as several conditions of the thyroid gland or, less commonly, the pituitary gland or...
, cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
, palliative care
Palliative care
Palliative care is a specialized area of healthcare that focuses on relieving and preventing the suffering of patients...
, mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
, asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
.
Added in 2006 were dementia
Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
, depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
, chronic kidney disease, atrial fibrillation
Atrial fibrillation
Atrial fibrillation is the most common cardiac arrhythmia . It is a common cause of irregular heart beat, identified clinically by taking a pulse. Chaotic electrical activity in the two upper chambers of the heart result in the muscle fibrillating , instead of achieving coordinated contraction...
, obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
, learning disabilities, smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
.
QOF version 10 was introduced in July/August 2007, mainly minor changes to the system, removing, adding or changing codes in the clinical areas to bring them in line with current guidance or to fix typos.
Further changes to the QOF for 2008 include the addition of new indicators for COPD
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease , also known as chronic obstructive lung disease , chronic obstructive airway disease , chronic airflow limitation and chronic obstructive respiratory disease , is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases...
and smoking cessation
Smoking cessation
Smoking cessation is the process of discontinuing the practice of inhaling a smoked substance. This article focuses exclusively on cessation of tobacco smoking; however, the methods described may apply to cessation of smoking other substances that can be difficult to stop using due to the...
. Points have been removed from the access and patient experience domains.
Exception reporting
The level of achievement recorded depends on the GP treating the patients with the relevant problem. But not all patients are treatable or willing to be treated. In order for the GPs not to lose points on account of circumstances that are outside their control they can exclude those patients from counting towards their achievement by "exception reporting" them. Exception reporting is allowed for:- patients who refuse to attend;
- patients for whom chronic disease reporting is inappropriate (e.g. terminal illness, extreme frailty);
- newly diagnosed or recently registered patients;
- patients who do not show improvement;
- patients for whom prescribing a medication is not clinically appropriate;
- patients not tolerating medication;
- patients refusing investigation or treatment (informed dissent);
- patients with supervening conditions;
- cases where diagnostic/secondary care service is unavailable.
Practices in Scotland have been found to use exception reporting appropriately in that patients who were older or who had dementia were more likely to have been "exception reported". However, younger or more socio-economically deprived patients were more likely to be recorded as having refused to attend for review or not replying to letters asking for attendance at primary care clinics. It has therefore been highlighted that primary care practices should identify and monitor these individuals (i.e. the youngest and most deprived with cardiovascular disease) so that all patients fully benefit from the implementation of the new GMS contract and receive appropriate clinical care to prevent further disability and mortality.
Advantages and disadvantages
Assessments of its success are mixed. The new GP contract as a whole cost £1.76 billion more than the Government had expected, mainly because GPs had been expected to achieve 75% of the available points in the first year and actually achieved 90%.Tim Burr, head of the NAO, said in 2008: “There is no doubt that a new contract was needed and there are now 4,000 more GPs than five years ago. But in return for higher pay, we have yet to see real increases in productivity.”
However, substantial improvements have been noted, particularly in the maintenance of disease registries and screening of risk factors for older patients with cardiovascular disease in the community.
Ben Bradshaw, the Health Minister said: “The GP contract... has stemmed the haemorrhaging of GPs from the NHS and improved the quality of care for the public. Longer consultations, quicker appointments and being able to book ahead are improvements valued by patients.”
Laurence Buckman, chairman of the BMA’s GP committee, said “The early evidence is that the contract is leading to improvements in clinical care".
External links
- A collection of articles for GPs and practice managers by Dr Simon Clay, a GP in Erdington Birmingham.
- NHS Information Centre official publication website for QOF data
- QOF Database Detailed and summary data produced from practice returns for QOF.
- Key documents detailing the QOF
- Business Rulesets used to determine QOF achievement