BMA - The Quality and Outcomes Framework must be the same across the UK for the benefit of patients, says BMA - 30 Oct 08

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Any changes to the Quality and Outcomes Framework (QOF)1 must build on the significant improvements in quality and consistency of care that its introduction has already achieved, and must not lead to a postcode lottery in patient care, the BMA said today (Thursday 30 October 2008).

Commenting on the launch of a Department of Health consultation document on the QOF, Dr Laurence Buckman, Chairman of the BMA’s GP Committee (GPC), said:

• “The introduction of the QOF into the new GP contract marked a huge step forward in the government’s promise to address health inequalities across the UK. It is doing exactly what it was supposed to do by ensuring that patients get consistent, evidence-based care wherever they live. It has introduced a systematic process of care for the diseases responsible for the majority of the deaths in this country – in short QOF saves lives. We would be concerned if this review undermined this vital national approach to quality standards. There is the possibility of a postcode lottery in patient care developing if Primary Care Organisations can choose which bits of QOF they want to provide. Patients should expect the same high quality of care wherever they live in the UK.
• “It was always intended that QOF should evolve as the evidence improves and since its inception approximately a quarter of it has changed. Its evolution under NICE must continue to be based on evidence that interventions in primary care make a difference to patients, to ensure that the improvements we have seen in clinical care continue. Any changes as a result of the review will still require contractual negotiation and as such the GPC expects to continue to have a full role in QOF development in the future.”

The BMA will be responding formally to the Department of Health consultation.

Note:

1) The Quality and Outcomes Framework was introduced in April 2004 as part of the new national GP contract. It offers practices up to 1000 points if they deliver on a range of services. These points attract financial resources into the practice. Most of the points relate to evidence-based clinical interventions proved to benefit patients with illnesses such as asthma, diabetes and other long-term conditions: others are linked to the organisation and to patients’ experience of the practice.

For more information on the QOF and the improvements in the health outcomes for patients since the changes to the GP contract, including a case study on how the QOF works in a practice, please go to: http://www.bma.org.uk/ap.nsf/Content/QOFbrief0908

Related Stories:

• DH - Developing the Quality and Outcomes Framework: Proposals for a new, independent process - 30 Oct 08
• DH - Consultation on GP Quality Incentive Scheme launched - 30 Oct 08

 This is a public consultation document setting out proposals for how a  new independent and transparent process for recommending Quality Outcome Framework (QOF) indicators led by NICE should work. The DH will publish the responses and publish a report on how the consultation process influenced the development of policy.

• Download Developing the Quality and Outcomes Framework: Proposals for a new, independent process consultation document (PDF, 298K)
• Download impact assessment (PDF, 247K)

Executive Summary
We intend to ask NICE to oversee a new independent, transparent and objective process for developing and reviewing QOF clinical and health improvement indicators for England from 1 April 2009 as part of their role in providing guidance for the NHS based on evidence of clinical effectiveness and cost effectiveness.

The main elements of the new process would be:

• Collating information to inform the prioritisation of potential new indicators, including setting up a facility on the NICE website for interested parties to submit ideas for priority topics.
• Carrying out a prioritisation process to decide on areas for indicator development and advising on candidates for new indicators in these areas based on evidence of clinical and cost effectiveness.
• Ensuring that the existing clinical and health improvement indicators are regularly reviewed.
• Setting up a primary care consideration panel consisting of a range of experts and representatives from the field to consider the relative priority of potential new clinical and health improvement topics.
• Developing and piloting potential new indicators and reviewing existing indicators,applying a methodology for assessing cost-effectiveness. NICE propose to appoint an external contractor through a competitive tender process to carry out this work.
• Carrying out a consultation on the developed indicators during the piloting phase.
• Validating the final proposals for new and reviewed indicators through the primary care consideration panel and publishing its conclusions via the NICE website.
• Giving advice on:
  – time limits for new indicators after which they should be reviewed;
  – the potential lower and upper thresholds for new indicators based on information about baseline uptake and expected increased uptake;
  – information based on the assessment of cost-effectiveness evidence to inform the financial value of indicators;
  – guidance on the application of existing indicators in the light of the latest evidence.

Independent research shows that QOF is reducing the gap in performance between practices in areas of high and low deprivation6. Our proposals are designed also to build on the ability of QOF to help reduce health inequalities and respond to the needs of our diverse society.

At national level NHS Employers (on behalf of the Department of Health) would then (as now) negotiate with the BMA on which indicators should be applied nationally (or, with the agreement of the devolved administrations, across the UK as a whole) and what the value of those indicators should be.

We are also seeking views on the proposal that Primary Care Trusts (PCTs) could in future select additional indicators from the NICE menu to reflect local priorities, using either resources devolved for this purpose or local resources.

Introduction
1. As part of the NHS Next Stage Review4, we announced proposals for developing the Quality and Outcomes Framework (QOF) including an independent and transparent process for developing and reviewing indicators.

2. This formed part of a wider set of proposals to support continuous quality improvements across primary and community care and to promote healthy lives. The strategy was informed by an external advisory board, bringing together leading GPs, other primary care professionals and representatives of other stakeholders, and based on extensive discussion with members of the public, with clinicians across the NHS and with colleagues from other sectors.

3. The report said that we would:

• discuss with the National Institute for Health and Clinical Excellence (NICE) and with professional and patient groups how this new process should work;
• explore how to give greater flexibility to PCTs to select indicators (from a national menu) that reflect local health improvement priorities.

4. In developing these proposals, we have also taken into account the recommendations of the National Audit Office (NAO) report on GP contract modernisation5. The NAO recommended that the Department should:

• develop a long term strategy to support yearly negotiations on the QOF and develop the QOF based on patient needs and in a transparent way
• base the strategy more on outcomes and cost effectiveness
• agree to allocate a proportion of QOF indicators for local negotiation at Strategic Health Authority (SHA) or PCT level
• consider the case for time-limiting QOF points.

5. Independent research shows that QOF is reducing the gap in performance between practices in areas of high and low deprivation6. Our proposals are designed also to build on the ability of QOF to help reduce health inequalities and respond to the needs of our diverse society.

6. We intend that NICE should oversee a new independent process for developing and reviewing QOF clinical and health improvement indicators for England from 1 April 2009 as part of their role in providing guidance for the NHS based on evidence of clinical effectiveness and cost effectiveness. The process would involve reviewing existing QOF indicators, prioritising areas for new indicators, and developing and
recommending new indicators. It would be informed by open consultation with stakeholders, including patient and professional groups, and based on best available evidence of clinical and cost effectiveness.

7. In summary, NICE would manage an independent and transparent approach to produce a national menu of approved indicators made available through the NICE website from which:

• NHS Employers (on behalf of the Department of Health) would negotiate with the BMA on which indicators should be applied nationally (or, with the agreement of the devolved administrations, across the UK as a whole) and what the value of those indicators should be;
• PCTs could potentially select additional indicators that reflect local priorities using either resources specifically devolved for this purpose or other local resources.

8. This consultation document sets out the proposed principles and framework for how the new process would work in England and invites comments from professional, patient and carer representatives, PCTs and other groups or individuals who may be interested.
9. Following the results of this Department of Health consultation, we envisage that NICE would publish on their website an interim process document setting out in detail how they would propose to manage the new process and the proposed methodology for assessing indicators.

6. We intend that NICE should oversee a new independent process for developing and reviewing QOF clinical and health improvement indicators for England from 1 April 2009 as part of their role in providing guidance for the NHS based on evidence of clinical effectiveness and cost effectiveness. The process would involve reviewing existing QOF indicators, prioritising areas for new indicators, and developing and
recommending new indicators. It would be informed by open consultation with stakeholders, including patient and professional groups, and based on best available evidence of clinical and cost effectiveness.

7. In summary, NICE would manage an independent and transparent approach to produce a national menu of approved indicators made available through the NICE website from which:

• NHS Employers (on behalf of the Department of Health) would negotiate with the BMA on which indicators should be applied nationally (or, with the agreement of the devolved administrations, across the UK as a whole) and what the value of those indicators should be;
• PCTs could potentially select additional indicators that reflect local priorities using either resources specifically devolved for this purpose or other local resources.

8. This consultation document sets out the proposed principles and framework for how the new process would work in England and invites comments from professional, patient and carer representatives, PCTs and other groups or individuals who may be interested.

9. Following the results of this Department of Health consultation, we envisage that NICE would publish on their website an interim process document setting out in detail how they would propose to manage the new process and the proposed methodology for assessing indicators.
Other UK countries

10. We are discussing with the devolved administrations how to continue to ensure a collaborative approach to developing and reviewing indicators across the four UK countries. The major diseases are common across the UK, but there will be differences in health needs between countries and within countries. We envisage a situation where it may be possible for each of the four countries to remain within a UK
framework but be able to choose indicators from a UK menu that fit with national or local priorities.

11. NICE is responsible for evidence based guidelines for England, Wales and Northern Ireland. There is already good collaboration between NICE and NHS Quality Improvement Scotland, which leads the use of knowledge to promote improvement in the quality of healthcare in Scotland.

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