QOF Plus Year 1 - Imperial College London

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Effect of measurement on health inequalityMant (2008) comments that “in everyday clinical practice, variability in usual care matters mostat the tail-end of the distribution where poor care can lead to adverse outcomes includingavoidable death.” Evidence from epidemiological studies suggest that while effective regularmechanisms for dealing with poor care are essential, a more effective approach is to developstrategies for raising average performance, and therefore shifting the whole distribution (Rose etal., 1990). An example of this is the introduction of cervical smear targets for UK general practicesin 1990. The highest targets were achieved rapidly by practices in affluent areas, and this resultedin an initial widening of the health inequality gap. However, practices in more deprived areascaught up over the next few years, thereby reducing inequality (Baker et al., 2003; Middleton etal., 2003). This phenomenon has been termed the inverse equity hypothesis (Victora et al., 2000).This hypothesis predicts that the benefits of new public health interventions are initiallyexperienced by the wealthier sector of the population and later by the poor, increasing theinequity ratio. However, once the poor have experienced benefits and a ceiling effect is reachedin the richer population, the inequity ratio which initially increases, then decreases.Although the Quality and Outcomes Framework was not designed to tackle health inequalities(Roland, 2004), there is evidence of the inverse equity hypothesis being relevant to QOF. Data isnow emerging which suggests that from a longer term perspective, more equitable healthcare isbeing generated following the introduction of QOF (Lester, 2008). Ashworth et al. (2008) assessedthe effects of social deprivation on levels of BP monitoring and control using data from over 97%of practices in England over the first three years of the QOF. They found that:“Since the reporting of performance indicators for primary care and the incorporation ofpay for performance in 2004, blood pressure monitoring and control have improvedsubstantially. Improvements in achievement have been accompanied by the neardisappearance of the achievement gap between least and most deprived areas.”Doran et al. (2008) looked at overall achievement in 48 of the clinical indicators in QOF and foundthat median achievement score increased across the board, with the gap in median achievementbetween practices in the most and least deprived areas reducing considerably.The evidence suggests that “low scoring practices in deprived areas also seem just as able toimprove the quality of their care (as measured by the Framework) as low scoring practices inmore affluent areas” (Lester, 2008). Lester (2008) further comments that:“Overall, the financial incentives seem to have reached areas of high need relativelyeffectively for most targets. An important subsidiary message is the need to take a longterm view when interpreting the effects of quality measures on health inequalities.”However, there remains concern that QOF may not encourage practices in reaching the morechallenging, hard-to-reach patients, as practices do not receive further incentives once they haveachieved the 90% upper threshold for payment (National Audit Office, 2008). This meanspractices can receive maximum points and payment for every clinical indicator before all eligiblepatients receive indicated care. Fleetcroft et al. (2008) comment that this can result in an‘incentive ceiling effect’ with associated reductions in health gains, and state that “there may beno rationale for maximum target thresholds to be set below 100% as there are comprehensivereasons for exception reporting any patient who would not theoretically benefit from theindicated care”. Setting and rewarding achievement of higher thresholds for selected existing4
QOF indicators may therefore help to address this issue, with the aim of achieving additionalhealth gains in a more challenging group of patients.Why have a local QOF?Local Enhanced Services (LES) already provide scope for local development within the GMScontract. The purpose of these is to allow PCTs to tackle local problems not addressed in thenational QOF. These may include a greater emphasis on prevention and strategies designed toreduce inequity. It is anticipated that introduction of a local QOF would confer a number ofadvantages, including more robust performance reporting, mainstreaming quality throughtemplates and coverage of a greater number of areas.The concept of developing a local QOF has recently received backing from the National AuditOffice (2008) and the NHS Next Stage Review (Darzi, 2008).Development and implementation of a local QOF may also contribute to PCTs fulfilling theirfunctions as World Class Commissioners. The Department of Health describes World ClassCommissioners as being “central to a self-improving NHS. They will operate as learningorganisations, seeking and sharing knowledge and skills. World class commissioners will also bestimulating provider and clinical innovation through improvements in experienced quality, accessand outcomes” (DoH, 2008). As part of this commissioning process, PCTs are required to “investlocally to achieve the greatest health gains and reductions in health inequalities, at best value forcurrent and future service users”.The World Class Commissioning programme (DoH, 2008) outlines a series of competencies whichcommissioners will need to reach world class status. These are:locally lead the NHSwork with community partnersengage with public and patientscollaborate with cliniciansmanage knowledge and assess needsprioritise investmentstimulate the marketpromote improvement and innovationsecure procurement skillsmanage the local health systemmake sound financial investments5
Page 1: Towards world class healthcare for
Page 6 and 7: QOF+ report on breastfeeding ......
Page 8 and 9: QOF+ report on patient safety .....
Page 10 and 11: CreditsProject boardJosip CarMiles
Page 12: AcknowledgementsWe are indebted to
Page 15 and 16: Executive summaryIntroductionPrevio
Page 18: Support with QOF+If you have a prob
Page 22 and 23: The quality and outcomes framework
Page 26 and 27: How might a local QOF operate in pr
Page 28 and 29: Doran T, Fullwood C, Kontopantelis
Page 30 and 31: Continued…QOFQOF+IndicatorUpperTh
Page 32 and 33: Alcohol Chapter 4 (p27)IndicatorQOF
Page 34 and 35: RecordsIndicator+ PRESCRIPTION 1. T
Page 36 and 37: Patient experience Chapter 12 (p77)
Page 39 and 40: C3QOF+ report on cardiovasculardise
Page 41 and 42: Creation of practice CVD at-risk re
Page 43 and 44: achieved through primary prevention
Page 45 and 46: Workload and training implicationsI
Page 47 and 48: QOF+ report on alcoholProposed indi
Page 49 and 50: Local contextThe Hammersmith and Fu
Page 51 and 52: Workload and training implicationsR
Page 53 and 54: QOF+ report on smokingProposed indi
Page 55 and 56: Local context24% of adults (35,000)
Page 57: ReferencesBritish Medical Associati
Page 60 and 61: The NICE Clinical Guideline on Ante
Page 62 and 63: Health impactThere are significant
Page 65 and 66: QOF+ report on breastfeedingPropose
Page 67 and 68: Local contextIn 2006/7, the percent
Page 69 and 70: Degree of perceived professional co
Page 71 and 72: QOF+ report on ethnicityProposed In
Page 73 and 74: Associated Morbidity and MortalityT
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Workload and training implicationsP
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Priority and relevance to national
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Specific reasons for this framework
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Workload and training implicationsT
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QOF+ report on newpatient screening
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Review of evidence to support the p
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QOF+ report onpatient informationPr
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Priority and relevance to national
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Degree of perceived support from pa
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ReferencesCarpenter A and Mayers A
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QOF+ report onpatient experiencePro
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Rosen et al. (2001) categorised ini
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The National 2007 Quality and Outco
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ReferencesBaker, R (2007) Quality a
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BackgroundThe United Nations Conven
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In March 2008, a PCT audit of signi
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Impact on health inequalitiesPovert
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Training and support requirements f
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Information on self-directed online
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New patient screeningProposed train
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Patient experienceLearning disabili
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Appendix 1Background to the QOF+ de
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Appendix 2Methodology for the exten
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PrevalenceRegistersizeAsthma 5.75%
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While both threshold types are remu
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The low level of remuneration for c
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Exception reportingMany QOF (and a
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indicators compared to national rat
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114
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Appendix 3Current levels of attainm
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Percentage of practices at or below
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Appendix 4Methodology for the desig
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As a result of the prioritisation p
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Methodology for the development of
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Assessment of new clinical and reco
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Communication with the PCT’s heal
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Appendix 5Methodology for the devel
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Appendix 6Summary of the QOF+ schem
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QOF Plus Year 1 - Imperial College London

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