QOF Plus Year 1 - Imperial College London
QOF Plus Year 1 - Imperial College London QOF Plus Year 1 - Imperial College London
PrevalenceRegistersizeAsthma 5.75% 287Hypertension 12.79% 637Cancer 1.08% 54CHD 3.50% 175COPD 1.48% 74CS Eligible 25.00% 1244Diabetes 3.87% 193Epilepsy 0.60% 30LVD 0.75% 38Mental Health 0.73% 37Stroke and TIA 1.63% 82Thyroid 2.71% 135Table A2.2Adjusted prevalence figures and expected register size (absolute number of patients) for the medianHammersmith and Fulham practice of 4975 patients. Data sourced from QOF 07/08.The sigmoid nature of many of the attainment distributions seen ( see Appendix 3, p116)results in a tension between the desire to set a target that motivates even the best performingpractices (argues for a high target) but without discouraging those poorer participating practicesfrom participation at all in the scheme (argues towards a lower target). The possibility of basingthresholds on the performance of below-median practices (for example, restricting analysis topractices lying in the lower IQR for attainment) was considered but rejected because it uniformlyresults in large numbers of better-performing practices already attaining the revised target. Theissue of providing additional rewards to practices who have not needed to make anyperformance gain is sensitive from both a financial governance and political point of view. Thiswas ultimately addressed by capping the number of NHS Hammersmith and Fulham practiceswho already exceed the QOF+ revised thresholds at four (i.e. whenever more than 4 practicesmet a candidate threshold, it was discounted.) To address the needs of poorer performingpractices for whom the thresholds may represent large jumps in attainment, it was decided thatspecific resources be made available to support them, instead of trying to revise the targetdownward.The target-setting scheme for the revised QOF+ threshold was ultimately based on an iterativeapproach that started from the 75 th national centile for QOF 07/08 (selected after analysis of themedian distances for each indicator) and revised up in 5 centile increments whenever the cappingrule described above was violated. The thresholds set by this scheme and the centiles on whichthey are based, together with the median distance and expected patient numbers aresummarised in Table A2.4. Consultation with local practices raised concerns about theconsequence of ‘all-or-nothing’ rewards on marginal errors (i.e. accidentally missing a singlepatient). To address this, an indicator-specific tolerance was introduced to provide a ‘cushion’against these errors.The tolerance is the difference between the original QOF+ threshold and a new lower thresholdcalculated using the original capping method but removing the 75 th national centile floor and the104
5-centile step. This lower value is termed the Tolerance threshold. Details of these and theoriginal QOF+ thresholds are summarised below:ToleranceThreshold Based on PointsMediandistanceExpected# PatientsPractices ≥ThresholdASTHMA 6 92% 90th 5 11.5% 33 2BP 5 88% 91st 15 10.1% 65 2CHD 6 97% 92nd 3 7.6% 14 1CHD 8 85% 61st 4 5.3% 10 2CHD 10 86% 82nd 7 18.1% 32 3CS 1 81% 31st 18 9.6% 119 3DM 12 85% 73rd 3 4.2% 9 4DM 17 87% 71st 5 7.8% 16 3DM 20 76% 83rd 10 10.4% 20 3MH 6 96% 77th 2 8.8% 4 3STROKE 6 95% 87th 3 6.1% 6 3STROKE 8 84% 77th 3 9.0% 8 3Table A2.3Lower (Tolerance) QOF+ thresholds for the 12 clinical indicators taken from QOF. The medianimprovement that a practice would have to make to reach the target is shown as well as the number ofpatients that this improved would involve for the median Hammersmith and Fulham practices. Thenumber of practices already exceeding Tolerance thresholds is shown.QOF+Threshold Based on PointsMediandistanceExpected# PatientsPractices ≥ThresholdASTHMA 6 95% 95th 5 14.5% 42 0BP 5 90% 95th 14 12.1% 78 0CHD 6 98% 95th 3 8.6% 16 0CHD 8 87% 75th 3 7.3% 13 1CHD 10 87% 85th 7 19.1% 34 3CS 1 88% 75th 17 16.6% 206 0DM 12 86% 75th 2 5.2% 11 3DM 17 88% 75th 4 8.8% 17 3DM 20 77% 85th 10 11.4% 22 2MH 6 97% 80th 1 9.8% 4 2STROKE 6 96% 90th 3 7.1% 6 2STROKE 8 85% 80th 2 10.0% 9 3Table A2.4Default QOF+ thresholds for the 12 clinical indicators taken from QOF. The median improvement that apractice would have to make to reach the target is shown as well as the number of patients that thisimproved would involve for the median Hammersmith and Fulham practices. The number of practicesalready exceeding these thresholds is shown.105
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5-centile step. This lower value is termed the Tolerance threshold. Details of these and theoriginal <strong>QOF</strong>+ thresholds are summarised below:ToleranceThreshold Based on PointsMediandistanceExpected# PatientsPractices ≥ThresholdASTHMA 6 92% 90th 5 11.5% 33 2BP 5 88% 91st 15 10.1% 65 2CHD 6 97% 92nd 3 7.6% 14 1CHD 8 85% 61st 4 5.3% 10 2CHD 10 86% 82nd 7 18.1% 32 3CS 1 81% 31st 18 9.6% 119 3DM 12 85% 73rd 3 4.2% 9 4DM 17 87% 71st 5 7.8% 16 3DM 20 76% 83rd 10 10.4% 20 3MH 6 96% 77th 2 8.8% 4 3STROKE 6 95% 87th 3 6.1% 6 3STROKE 8 84% 77th 3 9.0% 8 3Table A2.3Lower (Tolerance) <strong>QOF</strong>+ thresholds for the 12 clinical indicators taken from <strong>QOF</strong>. The medianimprovement that a practice would have to make to reach the target is shown as well as the number ofpatients that this improved would involve for the median Hammersmith and Fulham practices. Thenumber of practices already exceeding Tolerance thresholds is shown.<strong>QOF</strong>+Threshold Based on PointsMediandistanceExpected# PatientsPractices ≥ThresholdASTHMA 6 95% 95th 5 14.5% 42 0BP 5 90% 95th 14 12.1% 78 0CHD 6 98% 95th 3 8.6% 16 0CHD 8 87% 75th 3 7.3% 13 1CHD 10 87% 85th 7 19.1% 34 3CS 1 88% 75th 17 16.6% 206 0DM 12 86% 75th 2 5.2% 11 3DM 17 88% 75th 4 8.8% 17 3DM 20 77% 85th 10 11.4% 22 2MH 6 97% 80th 1 9.8% 4 2STROKE 6 96% 90th 3 7.1% 6 2STROKE 8 85% 80th 2 10.0% 9 3Table A2.4Default <strong>QOF</strong>+ thresholds for the 12 clinical indicators taken from <strong>QOF</strong>. The median improvement that apractice would have to make to reach the target is shown as well as the number of patients that thisimproved would involve for the median Hammersmith and Fulham practices. The number of practicesalready exceeding these thresholds is shown.105
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