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Focus on the Quality and Outcomes Framework 2006

February 2006

What has changed

• Appendix 1 - QOF points - removal, redistribution, assignment
• Appendix 2 - Changes to the text of existing indicators
• Background
• Exception reporting
• Indicator points redistributed
• Indicator points removed
• New indicators
• Smoking indicators reconfiguration
• The agreement on points
• Thresholds

This guidance gives an overview of what changes have been made to the Quality and Outcomes Framework (QOF), what has come out, what has gone in and the reason why this was done. For a full list of all the indicators in the new QOF and the guidance related to them please refer to the BMA website ‘The Quality and Outcomes Framework 2006’ .

Background
The Quality and Outcomes Framework has always been a key component of the new general medical services (GMS) contract. It has rewarded the delivery of high-quality general practice over the last few years by supporting the provision of an excellent service to both patients and the NHS.

It has also been critical in ensuring adequate remuneration of GPs for the service they provide. From its inception, it was always intended that it would be reviewed in light of new clinical evidence and the evolving nature and work of general practice.

The QOF review process started in February 2005 with the appointment of the University of Birmingham in conjunction with the Royal College of General Practitioners (RCGP) and the Society of Academic Primary Care to form the expert panel. An open call for evidence was then held from 18th April 2005 to 30th May 2005. In total 514 submissions were received. The expert panel reviewed all the submissions and provided recommendations for both modifications of existing indicators and potential new indicators to the negotiating parties, NHS Employers and the General Practitioner Committee (GPC). The negotiating parties spent the following months considering the expert group reports and negotiating the evidence-based changes. During this period of the negotiations, the expert panel were available, and clarified questions of evidence for all parties. The Quality and Outcomes Framework was also reviewed in relation to practice achievement, which included analysing the results of Quality and Outcomes Framework Management and Analysis system (QMAS) for threshold trends.

The Agreement on Points
The QOF negotiations took place within the context of the review of the entire new GMS contract. In light of the new funding available for the new contract, it was agreed that 138 points would be removed from the QOF to be replaced with new indicators and clinical domains. A further 28 points were redistributed amongst the current indicators.

A full list of those indicator points removed, redistributed and added is attached at Appendix 1 .

A full list of text changes to existing indicators is presented at Appendix 2 .

Indicator Points Removed
Holistic points and Quality Practice Payments
Eighty holistic and all the quality practice points were removed as part of the deal to reduce the current QOF by 138 points and to allow the inclusion of new clinical areas. Twenty holistic points remain to encourage practices to engage across the board in both the old and new clinical indicators.

Asthma 7
The removal of this indicator, for the flu vaccination of patients with asthma, was because there was no longer supporting evidence to prove that it is of benefit.

Mental Health 3, 4 and 5
These indicators relate to the monitoring of patients on lithium therapy. It was recognised by the experts and negotiating teams that these indicators covered a very small percentage of patients. It was felt that Mental Health 3 could be made redundant as Mental Health 4 and 5 provided sufficient monitoring. Equally, because of the small number involved, the points for MH4 and 5 were reduced.

Disease Registers
Nine of the disease registers were reduced in points. This was because, in most cases, it was recognised that the largest piece of work had already been achieved with the setting up of the registers. Although work was needed to maintain the registers, this was generally less demanding than setting it up. Where maintaining the register will still require significant work, as is the case with cancer, the reduction in points was minimal.

Organisational points
Records 1, 2, 4, 5, 6, 7, 12 and 14 were removed because it was recognised that all these indicators should be met by practices maintaining a level of clinical care that was professionally competent.

Information for patients 1, 2, 6 and 8 were removed as they were deemed to cover information that would necessarily be presented to patients already and there were issues with Records 8 with regard to telephone systems which made this quality indicator redundant.

Management 2 and 10 were reduced in points. Management 2 should be followed by all practices as a matter of course and Management 10 represents best employment practice. The points remaining in these indicators acknowledge the workload involved in completing them.

Medicines 1 was removed as this is standard practice and it was felt it should not remain in the QOF.

Indicator points redistributed
Twenty eight points taken out of the QOF were redistributed amongst existing indicators. This corresponded to indicators where it was felt that the extra work required to achieve them was not adequately reflected in the money available through them.

Clinical indicators
Analysing the QOF results for all practices using QMAS data, it was possible to see which indicators practices were having the most difficulty achieving. In order to encourage a higher percentage achievement the following indicators were each given an extra point: CHD8, BP5, DM6, DM12, COPD 6, COPD 7.

Organisation indicators
It was recognised that summarising records was an extremely demanding task for practices to keep up to date with. In light of this a further summarising indicator, with a 70% target has been introduced to further incentivise practices who have reached the 60% indicator but find the 80% target too demanding.

Significant event reviews are important educational tools and the points for them have been increased and the explanatory text has also been altered. This is to encourage reflective working within practices. “Near-misses” can also be included within this review.

Eight points have been added to the Patient Experience indicators. The patient experience survey and follow-up actions are an important mechanism for improving practice in relation to patient-specific feedback. To do the job well requires time and money, this is reflected in the higher point value put into these indicators.

Smoking indicators reconfiguration
All the smoking and smoking cessation indicators in the CHD, Stroke, Hypertension, Diabetes, COPD and Asthma clinical domains were removed from the disease indicator sets and placed within two specific smoking indicators. Their point value was also carried over into the new smoking indicators (ie: 68 points were removed from the clinical indicator sets and distributed 33 and 35 points in the new smoking indicators).

New indicators
The process of deciding on the new areas of work to be introduced to the QOF involved appraising the submitted evidence and then prioritising their clinical importance in primary care. There were 138 points available for new indicators. There was very strong evidence supporting the inclusion of indicators in the following clinical disease areas:

Atrial Fibrillation
Chronic Kidney Disease
Dementia
Depression
Mental Health
Palliative Care

The evidence will be published on the RCGP/University of Birmingham website.

Furthermore, new indicators were introduced for the setting up of an Obesity register and Learning Disability register. The obesity register can aid the formulation of public health policy and the learning disability register can enable further work on defining the service and development needs of patients with a learning disability.

One point was also awarded to recording the ethnic origin of patients when they register at the practice. This brings such recording into line with the rest of the NHS. Patients can decline to record this information and practices can choose not to take part in this or any other indicator.

Many other sets of evidence were submitted for other diseases, some of them of considerable importance. None of these were ignored but only a number could be incorporated and resourced through the QOF. Within this context it should be remembered that QOF accounts for only a small proportion of general practice. The decision not to include a clinical area in QOF should not be interpreted as diminishing either the importance of the condition or the expectation that patients should receive appropriate care from their general practice.

Thresholds
Analysis of the overall QOF results showed very high achievement rates across all four nations. In light of this, and the determination that the QOF should be a tool that encourages the improvement of standards in general practice, all the lowest thresholds were raised to 40% and in most instances the higher threshold was raised to 90%. Where there was clear evidence that setting a 40% and 90% threshold would be likely to discourage work in specific indicators, or was clearly unachievable, thresholds were altered within a more reasonable range for those indicators (for example CHD6, 8,10 and 11) or left as they were (for example BP5).

Exception reporting
There have been no changes to the rules around exception reporting.

Appendix 1

QOF points - removal, redistribution, assignment

Indicator set	Points removed	Points remaining or indicator gone
Holistic points	80	20
Quality Practice Payments	30	gone
Asthma 7 (flu vaccs)	12	gone
Mental Health 3	3	gone
Mental Health 4	2	1
Mental Health 5	3	2
Disease registers
CHD	2	4
Stroke & TIA	2	2
Hypertension	3	6
COPD	2	3
Epilepsy	1	1
Hypothyroidism	1	1
Cancer	1	5
Mental Health	3	4
Asthma	3	4
Organisational
Records 1	1	gone
Records 2	1	gone
Records 4	1	gone
Records 5	1	gone
Records 6	1	gone
Records 7	1	gone
Records 12	2	gone
Records 14	3	gone
Info for patients 1	0.5	gone
Info for patients 2	0.5	gone
Info for patients 6	0.5	gone
Info for patients 8	1	gone
Management 2	0.5	1
Management 10	2	2
Medicines 1	2	gone
Total points taken: 166

28 for redistribution amongst existing indicators
138 for new indicators

Where they have gone

Redistributed indicators	Points added	Indicator new total
CHD08 1 17	1	17
BP05	1	57
DM06	1	17
DM12	1	18
COPD6	1	7
COPD7	1	7
Records 20 (70% summarising)	12	12
Education 2	2	6
PE1	3	33
PE2	5	25
Total	28

New indicators
Dementia	20
Depression	33
CKD	27
Atrial Fibrillation	30
Obesity	8
Palliative Care	6
Mental Health	9
Learning Disability	4
Records	1
Total	138

Appendix 2

Changes to the text of existing indicators

Textual changes are highlighted in bold. The indicator numbers have been changed to distinguish the changed indicator from the previous one when analysing data from QOF.

Stroke
Previous - Stroke 2
The percentage of new patients with presumptive stroke (presenting after 1 April 2003) who have been referred for confirmation of the diagnosis by CT or MRI scan

New - Stroke 11
The percentage of new patients with a stroke who have been referred for further investigation.

Previous - Stroke 9
The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless contraindication or side-effects are recorded).

New - Stroke 12
The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded).

Diabetes mellitus (DM)
Previous - DM1
The practice can produce a register of all patients with diabetes mellitus.

New - DM19
The practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has Type 1 or Type 2 diabetes

Previous - DM6
The percentage of patients with diabetes in whom the last HbA1C is 7.4 or less (or equivalent test/reference range depending on local laboratory) in last 15 months.

New - DM20
The percentage of patients with diabetes in whom the last HbA1C is 7.5 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months.

Previous - DM8
The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months.

New - DM21
The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months.
Change of number because change of read code in that now practices need to demonstrate patients have received screening

Previous - DM14
The percentage of patients with diabetes who have a record of serum creatinine testing in the previous 15 months.

New - DM22
The percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months.

Chronic Obstructive Pulmonary Disease (COPD)
Previous - COPD2, COPD3
The percentage of patients in whom diagnosis has been confirmed by spirometry including reversibility testing for newly diagnosed patients with effect from 1 April 2003
The percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing.

New - COPD9
The percentage of all patients with COPD in whom diagnosis has been confirmed by spirometry including reversibility testing.

Previous - COPD6
The percentage of patients with COPD with a record of FeV1 in the previous 27 months

New - COPD10
The percentage of patients with COPD with a record of FeV1 in the previous 15 months

Previous - COPD7
The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the preceding 27 months.

New - COPD11
The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the previous 15 months.

Epilepsy
Previous - Epilepsy 1
The practice can produce a register of patients receiving drug treatment for epilepsy.

New - Epilepsy 5
The practice can produce a register of patients aged 18 and over receiving drug treatment for epilepsy

Previous - Epilepsy 2
The percentage of patients age 16 and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months.

New - Epilepsy 6
The percentage of patients age 18 and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months.

Previous - Epilepsy 3
The percentage of patients aged 16 and over on drug treatment for epilepsy who have a record of medication review in the previous 15 months.

New - Epilepsy 7
The percentage of patients age 18 and over on drug treatment for epilepsy who have a record of medication review involving the patient and/or carer in the previous 15 months

Previous - Epilepsy 4
The percentage of patients age 16 and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the last 15 months.

New - Epilepsy 8
The percentage of patients age 18 and over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the previous 15 months.

Cancer
Previous - Cancer 2
The percentage of patients with cancer diagnosed from 1 April 2003 with a review by the practice recorded within six months of confirmed diagnosis. This should include an assessment of support needs, if any, and a review of co-ordination arrangements with secondary care.

New - Cancer 3
The percentage of patients with cancer, diagnosed within the last 18 months, who have a patient review recorded as occurring within 6 months of the practice receiving confirmation of the diagnosis.

Mental health (MH)
Previous - MH1
The practice can produce a register of people with severe long-term mental health problems who require and have agreed to regular follow-up

New - MH8
The practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses.

Previous - MH2
The percentage of patients with severe long-term mental health problems with a review recorded in the preceding 15 months. This review includes a check on the accuracy of prescribed medication, a review of physical health and a review of co-ordination arrangements with secondary care.

New - MH9
The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceeding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status.

Asthma
Previous - Asthma 2
The percentage of patients aged eight and over diagnosed as having asthma from 1 April 2003 where the diagnosis has been confirmed by spirometry or peak flow measurement.

New - Asthma 8
The percentage of patients aged eight and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility.

Records and information about patients
Previous - Records 10
The smoking status of patients aged from 15 to 75 is recorded for at least 55% of patients.

Previous - Records 16
The smoking status of patients aged 15 to 75 is recorded for at least 75% of patients.

New - Records 22
The percentage of patients aged over 15 years whose notes record smoking status in the past 27 months, except those who have never smoked where smoking status need be recorded only once. (payment stages 40-90%)

Education
Previous - Education 2
The practice has undertaken a minimum of six significant event reviews in the past 3 years.

New - Education 10
The practice has undertaken a minimum of three significant event reviews within the last year.

Previous - Education7
The practice has undertaken a minimum of twelve significant event reviews in the past 3 years which include (if these have occurred):

• Any death occurring in the practice premises
• Two new cancer diagnoses
• Two deaths where terminal care has taken place at home
• One patient complaint
• One suicide
• One section under the Mental Health Act

New - Education7
The practice has undertaken a minimum of twelve significant event reviews in the past 3 years which could include:

• Any death occurring in the practice premises
• New cancer diagnoses
• Deaths where terminal care has taken place at home
• Any suicides
• Admissions under the Mental Health Act
• Child protection cases
• Medication errors
• A significant event occurring when a patient may have been subjected to harm, had the circumstance/outcome been different (near miss).

Medicines management
Previous - Medicines 5
A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines. Standard 80%

Previous - Medicines 9
A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines. Standard 80%

New - Medicines 11 and Medicines 12
Text remains unchanged in indicators but definition of medication review changes in guidance.

Patients experience
Previous - PE3 Patient Surveys (2)
The practice will have undertaken a patient survey each year, have reflected on the results and have proposed changes if appropriate.

New - PE5 Patient Surveys (2)
The practice will have undertaken a patient survey each year and having reflected on the results, will produce an action plan that:

1. Summarises the findings of the survey
2. Summarises the findings of the previous year’s survey
3. Reports on the activities undertaken in the past year to address patient experience issues

Previous - PE4 Patient Surveys (3)
The practice will have undertaken a patient survey each year and discussed the results as a team and with either a patient group or Non-Executive Director of the PCO. Appropriate changes will have been proposed with some evidence that the changes have been enacted.

New - PE6 Patient Surveys (3)
The practice will have undertaken a patient survey each year and, having reflected on the results, will produce an action plan that:

1. Set priorities for the next 2 years
2. Describes how the practice will report the findings to patients (for example, posters in the practice, a meeting with a patient practice group or a PCO approved patient representative)
3. Describes the plans for achieving the priorities, including indicating the lead person in the practice
4. Considers the case for collecting additional information on patient experience, for example through surveys of patients with specific illnesses, or consultation with a patient group

Smoking indicators reconfiguration
CHD 3, CHD 4, Stroke 3, Stoke 4, BP 2, BP 3, DM 3, DM 4, COPD 4, COPD 5, Asthma 4, Asthma 5 have been removed, with their points and reconfigured into:

Smoking 1 (33 points)
The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD or asthma whose notes record smoking status in the previous 15 months. Except those who have never smoked where smoking status need only be recorded once since diagnosis

Smoking 2 (35 points)
The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD or asthma who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months

Cervical screening
Previous CS2
The practice has a system to ensure adequate/abnormal smears are followed up.

Previous CS3
The practice has a policy on how to identify and follow up cervical smear defaulters. Patients may opt for exclusion from the cervical cytology recall register by completing a written statement which is filed in the patient record (exception reporting).

Previous CS4
Women who have opted for exclusion from the cervical cytology recall register must be offered the opportunity to change their decision at least every 5 years.

New CS7
The practice has a protocol that is in line with national guidance and practice for the management of cervical screening, which includes staff training, management of patient call/recall, exception reporting and the regular monitoring of inadequate smear rates.