Quality and outcomes in primary care
Josip Car
Quality and outcomes framework (QOF)
A national programme for quality improvement in primary care
Launched in 2004 as part of the revised GP contract
Pay-for-performance
132 chronic disease and administrative targets
Quality and outcomes framework (QOF)
Concrete evidence of improvement in areas covered by targets with
consequential impacts on disease and mortality Campbell et al., 2007; Millett et al., 2008;
Millett et al., 2009; Khunti et al., 2007; Mason et al., 2008; Shohet et al., 2007
But...
Perpetuating inequalities McLean et al. 2006; Millett et al., 2009 or not? Doran et al., 2008; Millett et
al., 2009 , Crawley et al. 2009
Halo effects Campbell et al., 2007; Sutton, 2010 or all-consuming? Steel et al., 2007
Methodological flaws? Guthrie et al., 2006; McLean et al. 2006
Too easy? Fleetcroft et al., 2008
The wrong focus? Darzi, 2008
Local schemes
Developed in response to the limitations of QOF
Better fit with local need
Increased focus on primary prevention
Capitalise on an existing mechanism
NHS Stoke on Trent
NHS Wandsworth
NHS Halton and St Helens
NHS Cambridgeshire and...
NHS Hammersmith and Fulham
Commissioning-academic partnership with Imperial College London
£2.5 million joint venture
Planning commenced June 2008
Launched December 2008
Slated to run until 2011
Looking back...
Concrete evidence of improvement in areas covered by targets with
consequential impacts on disease and mortality Campbell et al., 2007; Millett et al., 2008;
Millett et al., 2009; Khunti et al., 2007; Mason et al., 2008; Shohet et al., 2007
But...
Perpetuating inequalities McLean et al. 2006; Millett et al., 2009 or not? Doran et al., 2008; Millett et
al., 2009 , Crawley et al. 2009
Halo effects Campbell et al., 2007; Sutton, 2010 or all-consuming? Steel et al., 2007
Methodological flaws? Guthrie et al., 2006; McLean et al. 2006
Too easy? Fleetcroft et al., 2008
The wrong focus? Darzi, 2008
And....
A missed opportunity?
Looking forward...
Clinical engagement and ownership
Transparent
design
Training
Financial
incentives
Dedicated
support
Innovative IT
tools
The components of QOF+
Primary prevention
Cardiovascular disease primary prevention
Alcohol misuse in at-risk groups
Smoking cessation
Smoking in pregnancy
Breastfeeding uptake
New entrant TB screening
Care in vulnerable patient groups
Carer status recording
Ethnicity and first language recording
Higher targets for selected existing QOF indicators
Highlights from year 1
Smoking
128,118 (84%) people over 15 years old had smoking status
recorded
79% of the 26072 smokers identified were given smoking cessation
advice and referred to smoking cessation services
Smoking in Pregnancy
2,054 (98%) pregnant women
had smoking status recorded at booking
92% of the 168 smokers identified were given
smoking cessation advice and referred to smoking cessation services
Highlights from year 1
Alcohol screening and intervention
15,788 screened
2,724 (17%) screened positive
2,258
(83%) received brief intervention
Asthma checks
ASTHMA 6
100%
90%
85.9%
870
extra
patients with
an annual
asthma review
80%
Perfromance
78.8%
74.5%
70%
60%
8650 patients
with asthma
50%
National
H&F
40%
31-Mar-2006
31-Mar-2007
31-Mar-2008
Measurement Date
31-Mar-2009
31-Mar-2010
Prevalence
4.65% → 4.72%
315 extra patients
Blood pressure control
BP 5, CHD 6, DM 12, STROKE 6
1800 extra
100%
patients with
adequate BP
control
90%
Perfromance
80%
79.5%
77.8%
76.7%
70%
60%
28254 patients
50%
Prevalence
15.01 % → 15.43%
1350 extra patients
National
H&F
40%
31-Mar-2006
31-Mar-2007
31-Mar-2008
Measurement Date
31-Mar-2009
31-Mar-2010
Cholesterol control CHD 8, DM 17, STROKE 8
100%
590
extra
patients with
cholesterol
control
90%
Perfromance
80%
74.6%
73.8%
72.8%
70%
60%
10973 patients
50%
Prevalence
5.85 % → 5.99%
490 extra patients
National
H&F
40%
31-Mar-2006
31-Mar-2007
31-Mar-2008
Measurement Date
31-Mar-2009
31-Mar-2010
Mental health plans
MH 6
360
100%
90%
88.4%
extra
patients with
a care plan
83.5%
Perfromance
80%
75.6%
70%
2110 patients
with mental health
issues
60%
50%
National
H&F
Prevalence
1.03 % → 1.15%
260 extra patients
40%
31-Mar-2006
31-Mar-2007
31-Mar-2008
Measurement Date
31-Mar-2009
31-Mar-2010
Summary
The local QOF model can be implemented in practice
Some clear positive progress to date
Plenty of scope for improvement
Formal evaluation to start in summer 2010 with Imperial College London
An opportunity for study
There is clearly still plenty of scope for improvement!
Shifts in the focus of care into the community – strengthened by the coalition
plan for GP-lead commissioning – come at a time when funding will be
reduced
We perceive a methodological gap about best to do this. Is there a also
translational gap for implementation of QI in primary care?
Existing QOF indicators 1/2
QOF
QOF+
Points
ASTHMA 6. The percentage of patients with asthma who have had an asthma
review in the previous 15mths
70%
95% (3%)
10
BP 5. The percentage of patients with hypertension in whom the last blood
pressure (measured in the previous 9 months) is ≤150/90
70%
90% (2%)
29
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
70%
98% (1%)
6
CHD 8. The percentage of patients with coronary heart disease whose last
measured total cholesterol (measured in the previous 15 months) is ≤5mmol/l
70%
87% (2%)
7
CHD 10. The percentage of patients with coronary heart disease who are
currently treated with a beta blocker (unless a contraindication or side-effects
are recorded)
60%
87% (1%)
14
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
80%
88% (7%)
35
Continued...
Existing QOF indicators 2/2
QOF
QOF+
Points
DM 12. The percentage of patients with diabetes in whom the last blood
pressure is ≤145/85
60%
86% (1%)
5
DM 17. The percentage of patients with diabetes whose last measured total
cholesterol within the previous 15 months is ≤5mmol/l
70%
88% (1%)
9
DM 20. The percentage of patients with diabetes in whom the last HBA1c is
7.5 or less in the previous 15 months
50%
77% (1%)
20
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
50%
97% (1%)
3
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
70%
96% (1%)
6
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
60%
85% (1%)
5
New clinical QOF+ indicators
1/4
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 15 months
8
40-90%
+ 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 15 months
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 15 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 15 months
8
40-90%
+ 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)
8
40-90%
+ 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, siblings, or
children of a patient)
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
15 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%
New clinical QOF+ indicators
2/4
Points
Payment
stages
+ ALCOHOL 1. The percentage of patients on one or more practice registers for CVD AtRisk, Diabetes, Stroke and TIA, Hypertension and CHD who have had AUDIT-C or FAST
recorded on the practice system within the previous 15 months
15
20-70%
+ ALCOHOL 2. The proportion of patients who screen positive using either AUDIT-C or
FAST within the previous 15 months who are subsequently recorded as having a brief
intervention for alcohol misuse
30
40-90%
+ SMOKING 1. The percentage of patients aged 15 years or older whose notes record
smoking status in the past 15 months, or whose most recent recorded smoking status,
recorded over the age of 25, indicates that they had never smoked
20
40-90%
+ SMOKING 2. The percentage of patients aged 15 years or older 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 15 months
10
40-90%
+ 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
3
70-90%
+ 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)
5
70-90%
New clinical QOF+ indicators
3/4
Points
Payment
stages
+ BREASTFEEDING 1. The percentage of women who are recorded as being pregnant on
or after , and who at their antenatal booking appointment in primary care have been
given specific information on breastfeeding, including information on breastfeeding
workshops
4
70-90%
+ BREASTFEEDING 2. The percentage of babies born on or after 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
6
70-90%
+ BREASTFEEDING 3. At least 80% of babies born on or after December 01 2008 have a
record of feeding method at the time of the 6-8 week check
3
-
+ ETHNICITY 1. The percentage of patients on one or more practice registers for: CVD AtRisk, Hypertension, CHD, Diabetes, Mental Health and Stroke and TIA whose notes
record their ethnicity and first language
30
60-90%
+ ETHNICITY 2. The percentage of patients who have newly registered with the practice
on or after December 01 2008 whose notes record their ethnicity and first language
20
90-100%
New clinical QOF+ indicators
4/4
Points
Payment
stages
+ PRESCRIPTION 1. The percentage of individual repeat medications issued which have
a diagnosis or symptom in the electronic medical record relating to that medication.
45
70-90%
+ REFERRALS 1. The percentage of outpatient referrals made on or after December 01
2008 where both the referred-to speciality and diagnosis/symptom triggering referral
are coded on the clinical system
50
70-90%
+ CARERS 1. Carer status is recorded for 100% of individuals newly registered on or after
December 01 2008
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 non-clinical QOF+ indicators 1/4
Points
+ 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 from countries with a high TB prevalence
5
+ 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
3
+ PATIENT INFORMATION 2. The practice takes responsibility for regularly updating practice
information on the NHS choices website
7
+ 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.
3
New non-clinical QOF+ indicators 2/4
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 version of the 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
5
+ PATIENT EXPERIENCE 3. The practice shares with patients the results and action plan from the
national version of the 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
10
+ 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 local version of the Picker Institute patient satisfaction survey. Deviations
from the action plan must be described and explained
30
+ 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
5
+ 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
7
Continued...
New non-clinical QOF+ indicators 3/4
Points
+ 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
5
+ 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
+ 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 the survey
response to the statement “I waited more than 2 working days for a GP appointment”
20
+ PATIENT EXPERIENCE 11. The practice scores better than the national average on the survey
response to the question “Have you had a problem getting through to your GP practice/health
centre on the phone?”
20