QOF Plus Year 1 - Detailed Summary - Imperial College London

Quality and Outcomes
Framework Plus
Towards world class healthcare for all

The QOF+ approach
QOF+ is a major quality improvement initiative for primary care in Hammersmith & Fulham,
developed jointly by NHS Hammersmith and Fulham and Imperial College London. The PCT has
earmarked £2 million annual funding to implement the comprehensive initiative over the next 3
years with the aim of achieving a step-change in quality and to address local priorities.
Building on the success of the pay-for-performance model introduced through the national
Quality and Outcomes Framework (QOF), practices will be rewarded with QOF+ points for
achievement of higher thresholds for a selected number of existing national QOF indicators.
These indicators were chosen as attainment would result in significant health benefits and are
areas where Hammersmith and Fulham are currently underperforming:
Asthma
Hypertension
CHD
Cervical screening
Diabetes
Mental health
Stroke
Additionally, practices will be rewarded for achievement of new QOF+ indicators which have
been developed in clinical and non-clinical domains covering the following areas:
CVD primary prevention
Alcohol
Smoking
Smoking in pregnancy
Breastfeeding
Screening for tuberculosis
Ethnicity
Records
Patient experience
Patient safety
Patient information
Why have a local QOF?
It is anticipated that introduction of a local QOF would confer a number of advantages, including
more robust performance reporting, mainstreaming quality through templates and coverage of a
greater number of areas.
Development and implementation of a local QOF may also contribute to PCTs fulfilling their
functions as world class commissioners, investing locally to achieve the greatest health gains.
The concept of developing a national QOF has recently received backing from the National Audit
Office and the NHS Next Stage Review.
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Why run a separate scheme?
Early data suggest that the introduction of the national QOF has resulted in a moderate
improvement in patient care outcomes for some conditions. Local Enhanced Services (LES)
already provide scope for local development within the General Medicine Services (GMS)
contract to tackle local priorities and reduce health inequalities.
Despite this, there are some key limitations to both national QOF and LES, and QOF+ may
contribute to addressing these:
1 Insufficient focus on health outcomes:
The QOF+ advantage:
The current national QOF thresholds have arguably been set too low and once the
threshold is achieved, there are no further incentives to tackle the most challenging groups
of patients, increasing the chance of widening
health inequalities. Increased upper
thresholds for selected existing national QOF indicators encourages practices to reach
more challenging patient groups, with the aim of decreasing health inequalities, and
achieving significant health benefits.
2 Insufficient focus on primary prevention
The QOF+ advantage:
New clinical indicators developed as part of QOF+ have been designed specifically to focus
on primary prevention.
3 Nationally set targets don’t always reflect the local needs of patients
The QOF+ advantage:
With QOF+, new clinical and non-clinical indicators have been developed in response to
analysis of local health needs in Hammersmith and Fulham.
4 LES are often complex and uptake and monitoring can be problematic
The QOF+ advantage:
Evaluations of recently introduced LES and local Shared Care schemes (including CVD
Primary Prevention, Smoking Cessation and Alcohol) in Hammersmith and Fulham
highlighted a number of problems with these schemes, in terms of their complexity and
design and the level of uptake by practices. These highlight a need for widespread
implementation in a way that is easily understood.
QOF+ provides a more robust
performance reporting using templates for data entry combined with a training and
support package for practices.
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How QOF+ works...
Payment
QOF+ has adopted the same approach to payment as the national QOF scheme, using the same
value for a QOF+ point (1 point = £124.60). Like QOF, QOF+ includes a combination of all-ornothing
and payment stage indicators, re-uses the concept of exception reporting and
determines remuneration using a system of population and prevalence-weighted point
allocation.
Training & Support
A QOF+ Training and Support package has been developed to support implementation of QOF+.
The package encompasses a whole range of learning styles and preferences. Features include:
QOF+ Resource Pack for new indicator areas
In-house practice training
Educational meetings
Individual practice training budgets
IT support
QOF+ email support service
Provision of monthly feedback of performance to practices
Administration
Practices will receive regular feedback on attainment for new indicators, together with IT tools to
help with data entry and manage patient groups at a practice level. This enables practices to see
who is on the new disease registers and identify those who still need treating.
Monitoring & Evaluation
A programme of multimodal evaluation, currently under development, aims to assist monitoring
of the scheme and to support the PCT in its efforts to better understand health inequalities within
Hammersmith and Fulham. It is hoped that this evaluation will assist in the identification and
design of future indicator areas.
Anonymised medical records of all registered patients will be stored centrally by the PCT through
the use of the APOLLO IT system by practices. This will enable analysis of performance, improved
practice profiling, equity assessment using patient-level data, and provision of monthly feedback
of performance to practices, as part of the wider training and support package which has been
developed to support QOF+. This will be a rich source of decision support data for the PCT.
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How QOF+ has been developed...
Engagement with local practices and other local provider services, feedback from patients and
discussions with national and international experts in health care quality improvement provided
insights which informed the development of the scheme.
Extension of existing clinical QOF targets
A number of existing QOF indicators were identified as candidates that might benefit from
additional incentivisation through the provision of revised upper targets. Indicator selection was
weighted towards those whose attainment confers significant potential health benefits at a
population level and where current attainment in Hammersmith and Fulham is below that seen
nationally.
Design and development of the new indicators for QOF+
Potential sources for new indicator areas were identified and prioritised on the basis of being
both local and national priorities. These were subjected to a consultation with local stakeholders
to select areas for indicator development for the first year of the scheme. The clinical areas
selected were identified as priorities on the basis of being included in both the Hammersmith and
Fulham PCT Annual Public Health Report and in the Key Performance Indicators from the
Healthcare Commission. Indicators are likely to change for subsequent years of QOF+ in line with
latest best evidence and potential changes to national QOF indicators.
Literature reviews of the evidence base were undertaken for each selected indicator area to
inform development of indicators.
Proposed new indicators were assessed using the OECD criteria of importance, scientific
soundness and feasibility. Each indicator was also assessed for clarity. This assessment was
informed by the views of local practices, a local stakeholder panel (through a structured
consultation with the aim of achieving consensus for the clinical and records domains), local
provider services and national and international experts in the proposed indicator areas.
The PCT Health Informatics Team was consulted to ensure that proposed indicators would work
within primary care IT systems, and practice templates for new indicator areas were designed for
use within EMIS and VISION systems
Training & Support
The development of a training and support package to support QOF+ was informed by
consultation with local and national experts, analysis of data on achievement for existing QOF for
individual practices, and a training and support needs assessment conducted among all local
practices.
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For more information
If you would like any further information about QOF+, please contact:
Josip Car
Project Executive & Clinical Lead
josip.car@hf-pct.nhs.uk
Tel 020 3313 7175
Miles Freeman
Project Executive & Management lead
miles.freeman@hf-pct.nhs.uk
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Summary of indicators
Higher thresholds for existing clinical QOF indicators
Practices will receive a fixed number of QOF+ points for reaching or exceeding each of two higher
thresholds for the indicators detailed below. Point awards will be in addition to those allocated under
QOF and based on attainment at close of business on March 31 2010.
QOF
QOF+
Indicator
Upper Threshold
Threshold
(Tolerance) †
Points
ASTHMA 6. The percentage of patients with asthma who have had an
asthma review in the previous 15mths
BP 5. The percentage of patients with hypertension in whom the last blood
pressure (measured in the previous 9 months) is ≤150/90
CHD 6. The percentage of patients with coronary heart disease in whom the
last blood pressure reading (measured in the previous 15 months) is
≤150/90
CHD 8. The percentage of patients with coronary heart disease whose last
measured total cholesterol (measured in the previous 15 months) is
≤5mmol/l
CHD 10. The percentage of patients with coronary heart disease who are
currently treated with a beta blocker (unless a contraindication or sideeffects
are recorded)
CS 1. The percentage of patients aged from 25 to 64 whose notes record
that a cervical smear has been performed in the last five years
DM 12. The percentage of patients with diabetes in whom the last blood
pressure is ≤145/85
DM 17. The percentage of patients with diabetes whose last measured total
cholesterol within the previous 15 months is ≤5mmol/l
DM 20. The percentage of patients with diabetes in whom the last HBA1c is
7.5 or less in the previous 15 months
MH 6. The percentage of patients on the register who have a
comprehensive care plan documented in the records agreed between
individuals, their family and/or carers as appropriate
STROKE 6. The percentage of patients with a history of TIA or stroke in
whom the last blood pressure reading (measured in the previous 15
months) is ≤150/90 in the previous 15 months
STROKE 8. The percentage of patients with a history of TIA or stroke in
whom the last total cholesterol (measured in the previous 15 months) is 5
mmol/l or less
70% 95% (3%) 10
70% 90% (2%) 29
70% 98% (1%) 6
70% 87% (2%) 7
60% 87% (1%) 14
80% 88% (7%) 35
60% 86% (1%) 5
70% 88% (1%) 9
50% 77% (1%) 20
50% 97% (1%) 3
70% 96% (1%) 6
60% 85% (1%) 5
Under the current QOF 2009/10 proposal, DM20 will be replaced by DM23, which lowers the target for
HbA1c to ≤7.0. We recognise that attaining this more aggressive target will require significant effort
involving potentially large numbers of patients. To reward practices as they progress towards the revised
goal, we propose to retain DM20 within QOF+ until the end of March 2010. Since DM20 attainment status
will no longer be available through QMAS, feedback will instead be provided through the same
mechanism of monthly reporting used for the new QOF+ clinical indicators.
The introduction of a second, lower threshold aims only to address the concern that practices which
missed the original single target by small absolute numbers of patients would receive no payment at all.
This focus is why the gap between lower and upper thresholds is small in percentage terms.
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New QOF+ Indicators
Point awards will be based on attainment at close of business on November 30 2009.
Cardiovascular disease prevention
Indicator
QOF+ points
Payment
stages
+ CVD PREVENT 1. The percentage of patients on the Practice CVD At-Risk Register whose notes
have a Blood Pressure recorded in the previous 17 months
+ CVD PREVENT 2. The percentage of patients on the Practice CVD At-Risk Register whose notes
have a record of BMI measured in the previous 17 months
8 40-90%
8 40-90%
+ CVD PREVENT 3. The percentage of patients on the Practice CVD At-Risk Register whose notes
have a baseline record of total and HDL cholesterol recorded in the previous 17 months
8 40-90%
+ CVD PREVENT 4. The percentage of patients on the Practice CVD At-Risk Register for whom there
is a record of a fasting blood glucose in the previous 17 months
+ CVD PREVENT 5. The percentage of patients on the Practice CVD At-Risk Register whose notes
have a record of family history of CHD in first degree relatives (parents, brothers, sisters, or children
of a patient)
+ CVD PREVENT 6. The percentage of patients on the Practice CVD At-Risk Register whose notes
have a record of family history of diabetes in first degree relatives (parents, brothers, sisters, or
children of a patient)
8 40-90%
8 40-90%
8 40-90%
+ CVD PREVENT 7. The percentage of patients on the Practice CVD At-Risk Register who have been
offered lifestyle advice on exercise, and appropriate dietary changes within the previous 17 months
10 40-90%
+ CVD PREVENT 8. The percentage of patients on the Practice CVD At-Risk Register who have been
offered statin therapy (in line with 2008 NICE Guidance on Lipid Modification) as part of their
primary prevention management strategy
10 40-90%
It is prerequisite that in order to receive payment for + CVD PREVENT 1, practices have achieved the
existing QOF RECORDS 11 Indicator (The BP of patients aged 45 and over is recorded in the preceding 5
years for at least 65% of patients.)
Alcohol
Indicator
QOF+ points
Payment
stages
+ ALCOHOL 1. The percentage of patients on one or more practice registers for CVD At-Risk,
Diabetes, Stroke and TIA, Hypertension and CHD who have had AUDIT-C or FAST recorded on the
practice system within the previous 17 months
15 20-70%
+ ALCOHOL 2. The proportion of patients who screen positive using either AUDIT-C or FAST within
the previous 17 months who are subsequently recorded as having a brief intervention for alcohol
misuse
30 40-90%
It is prerequisite that in order to receive payment for + ALCOHOL 2, practices shall have reached the lower
threshold for + ALCOHOL 1.
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Smoking
Indicator
QOF+ points
Payment
stages
+ SMOKING 1. The percentage of patients aged over 15 years whose notes record smoking status
in the past 17 months, or whose most recent recorded smoking status, recorded over the age of
25, indicated that they had never smoked
20 40-90%
+ SMOKING 2. The percentage of patients aged over 15 years who smoke whose notes contain a
record that smoking cessation advice or referral to a local smoking cessation service has been
offered within the previous 17 months
10 40-90%
Smoking in pregnancy
Indicator
QOF+ points
Payment
stages
+ SMOKING IN PREG 1. The percentage of pregnant women whose notes record their smoking
status at the time of their first booking appointment in primary care
+ SMOKING IN PREG 2. The percentage of pregnant women who smoke whose notes contain a
record that at the time of their first antenatal booking appointment in primary care they have been
given smoking cessation advice and details of the local NHS Stop Smoking Services and the NHS
pregnancy smoking helpline (0800 169 9 169)
3 70-90%
5 70-90%
Breastfeeding
Indicator
QOF+ points
Payment
stages
+ BREASTFEEDING 1. The percentage of women who are recorded as being pregnant on or after
December 01 2008, and who at their antenatal booking appointment in primary care have been
given specific information on breastfeeding, including information on breastfeeding workshops
+ BREASTFEEDING 2. The percentage of babies born since December 01 2008 and breast fed at 6-8
weeks whose record indicates that breastfeeding support contact has been offered to the babies’
mother at the time of the 6-8 week check
+ BREASTFEEDING 3. At least 80% of babies born since December 01 2008 have a record of feeding
method at the time of the 6-8 week check
4 70-90%
6 70-90%
3 -
Ethnicity
Indicator
QOF+ points
Payment
stages
+ ETHNICITY 1. The percentage of patients on one or more practice registers for: CVD At-Risk,
Hypertension, CHD, Diabetes, Mental Health and Stroke and TIA whose notes record their ethnicity
and first language
+ ETHNICITY 2. The percentage of patients who have newly registered with the practice from
December 01 2008 whose notes record their ethnicity and first language
30 60-90%
20 90-100%
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Records
Indicator
QOF+ points
Payment
stages
+ PRESCRIPTION 1. The percentage of individual repeat medications issued which have a diagnosis
in the electronic medical record relating to that medication
+ REFERRALS 1. The percentage of outpatient referrals coded on clinical system with speciality and
diagnosis recorded
45 40-90%
50 70-90%
+ CARERS 1. Carer status is recorded for 100% of new registrations 6 -
+ OSTEOARTHRITIS 1. The practice is able to produce a register of patients who have osteoarthritis 1 -
+ RHEUMATOID ARTHRITIS 1. The practice is able to produce a register of patients who have
rheumatoid arthritis
1 -
+ ECZEMA 1. The practice is able to produce a register of patients who have eczema 1 -
+ PSORIASIS 1. The practice is able to produce a register of patients who have psoriasis 1 -
New patient screening
Indicator
+ PATIENT REGISTRATION 1. The practice is trained in and implements the PCT TB Early Referral Protocol to identify
and refer patients who are newly registered at the Practice and who are new entrants to the UK from countries with a
high TB prevalence
QOF+
points
5
Patient information
Indicator
+ PATIENT INFORMATION 1. The practice uses the PCT practice information leaflet template for patients which is
designed to include information on the following:
Preventative services such as stop smoking, immunization and screening
Choice / Choose & Book
PCT’s Patient Advice & Liaison Service and complaints team
Walk-in and urgent care centres
Practice opening times including extended hours
Information for patients in a range of languages informing them of their right to interpreting services during
appointments
+ PATIENT INFORMATION 2. The practice takes responsibility for regularly updating practice information on the NHS
choices website
+ PATIENT INFORMATION 3. The practice has up to date patient information about local training and support for self
management (in the form of posters and leaflets) and that these are clearly displayed for patients in waiting areas
QOF+ points
3
7
3
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Patient experience
Indicator
QOF+
points
+ PATIENT EXPERIENCE 1. The practice takes part in the national patient satisfaction survey 3
+ PATIENT EXPERIENCE 2. The practice takes part in a PCT-led feedback session based on the results of the national
patient satisfaction survey and agrees an action plan including explicit and appropriate targets that can be used in the
following 2 years to assess the extent to which the action plan is implemented
+ PATIENT EXPERIENCE 3. The practice shares with patients the results and action plan from the national patient
satisfaction survey. This should be through information leaflets and poster(s) in the practice’s waiting and reception
area, and through the Practice’s Patient Participation Group where this exists
+ PATIENT EXPERIENCE 4. The practice can show satisfactory objective evidence of implementing and achieving the
action plan agreed with the PCT following the PCT-led feedback session based on the results of the national patient
satisfaction survey. Deviations from the action plan must be described and explained
+ PATIENT EXPERIENCE 5. The practice has a register of patients who need signing and interpreting support for
appointments, including a record of first language spoken
+ PATIENT EXPERIENCE 6. The practice offers double length appointments to patients identified as needing interpreting
and signing support and to all patients on the learning disabilities register
+ PATIENT EXPERIENCE 7. 100% of carers who are newly registered with the Practice on or after December 01 2008 have
a record of being advised by the Practice that they can ask Social Services for an assessment of their own needs
+ PATIENT EXPERIENCE 8. The practice has a system in place for taking the special needs of carers into account,
including when allocating appointments and issuing prescriptions
5
10
30
5
7
5
5
+ PATIENT EXPERIENCE 9. A named carer is recorded for at least 90% of patients on the learning disability register 5
+ PATIENT EXPERIENCE 10. The practice scores better than the national average on their patients’ response to question
Q7 “Think about the last time you tried to see a doctor fairly quickly. Were you able to see a doctor on the same day or
in the next two days the GP surgery or health centre was open?” posed as part of the 2008/09 national patient
satisfaction survey
+ PATIENT EXPERIENCE 11. The practice scores better than the national average on their patients’ response to question
Q5a “In the past 6 months, how easy have you found getting through on the phone?” posed as part of the 2008/09
national patient satisfaction survey
20
20
Patient safety
Indicator
QOF+ points
+ PATIENT SAFETY 1. The practice submits significant event analysis (SEA) summaries to an annual PCT audit 4
+ PATIENT SAFETY 2. The practice can show evidence of reporting incidents or near misses involving harm/potential
harm to patients via the national reporting and learning system (NRLS) using the standard e-reporting form
+ PATIENT SAFETY 3. The practice has a system for ensuring that all practice staff have had CRB checks within the last
three years
+ PATIENT SAFETY 4. The practice has a system in place to assist, where appropriate, with the multi-agency referral
process for investigations relating to the protection of children and vulnerable adults, including acknowledging any
referrals or requests for information within 2 working days
+ PATIENT SAFETY 5. The practice has a system in place for identifying vulnerable children, and this includes cases where
a parent is known to be a substance misuser, has a severe mental health problem, or where there is domestic violence
+ PATIENT SAFETY 6. The case conference notes of all children who are the subject of a Child Protection Plan are scanned
into the child’s medical records
+ PATIENT SAFETY 7. The practice has a system in place for ensuring that where a child has been the subject of a child
protection plan, this is recorded as a Significant Active problem in the records of the child, the parents and other
members of the household, and that this leads to effective flagging of records
4
5
7
8
5
5
© Copyright NHS Hammersmith and Fulham 2009
© Copyright eHealth Unit, Department of Primary Care and Social Medicine, Imperial College 2008
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