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National QOF Consultation
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Tuesday 6 th January, Birmingham
Welcome & Introduction
Graham Urwin, Chief Executive, Stoke on Trent PCT
National QOF Consultation
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Tuesday 6 th January, Birmingham
Background to the Consultation
Ben Dyson, Director of Primary Care, Department of Health
High quality care for all is at the heart of the NHS Stage Review Final Report
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Help to stay healthy
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Empowering patients
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Most effective treatments for all
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Keeping patients as safe as possible Quality at the heart of the NHS
High quality care for all
High quality care for patients and the public
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Raising standards
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Stronger involvement of clinicians in decision making at every level of the NHS
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Fostering a pioneering NHS Freedom to focus on quality
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Empowering frontline staff to lead change that improves quality for patients
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Valuing the work of NHS staff
100 The Quality and Outcomes Framework was the first example of its kind in the world, introducing a dramatically more systematic focus on evidence-based care. 95 79 75 72 58 50 41 43 30 25 0 AUS CAN GER NETH NZ UK US Percent receive financial incentive: GPs are ahead of family doctors in comparator countries in uptake of financial incentives for quality, IT use and chronic disease management Managing patients with chronic disease/ Participating in quality improvement
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
There is also evidence that the QOF is reducing the gap in performance between practices in areas of high and low deprivation
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Average levels of achievement have increased over the three years of the QOF, and variation in achievement has diminished.
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In year 1, lower levels of achievement were associated with increased levels of deprivation and variation in achievement between practices increased with deprivation.
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In years 2 and 3, practices from the more deprived quintiles improved at the fastest rates and variation decreased.
Source: Doran Tet al; Effect of financial incentives on inequalities in the delivery of primary medical care in England: analysis of clinical activity indicators for the QOF,
The Lancet 2008; Vol 372
Recent research has shown that care for some chronic conditions improved more rapidly when QOF was introduced, although subsequent gains have been more difficult
Source: Campbell SM et al; National Primary Care Research and Development Centre •
The rate at which quality was improving increased for asthma and diabetes immediately following the introduction of the scheme
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The rate of improvement continued for coronary heart disease at the same rate as before the scheme
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In subsequent years, the rate of quality improvement appears to have slowed down
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QOF needs to be continually reviewed in order to support optimum health outcomes for patients
However, there have been criticisms of early QOF that its clinical indicator set didn’t correlate well with possible population health gains
• QOF indicators are not optimally aligned with interventions and activities that will have the maximum impact on population health • Cookson et al* correlated evidence on the population health gains from cardiac prescribing interventions with the relevant QOF payments • Plotted points associated with these interventions against likely lives saved p.a. per 100,000, with a relatively poor fit.
Source: Fleetcroft, R. and Cookson,, R. (2005) Do the incentive payments in the new NHS contract for primary care reflect likely population health gains? Journal of Health Care Research and Policy
The incentives in the Quality and Outcomes Framework for evidence based quality care are predominantly focused on diagnosis, management and secondary prevention of long term conditions.
Everyday activity Preventio n points Mostly disease manageme nt
Some primary prevention activity clearly takes place in GP practices, but there is no systematic framework for ensuring that people who need it have access to it or for measuring quality.
Only 7.5% of the QOF is dedicated to health promotion/illness prevention, covering: • registers for obesity and learning disability • recording blood pressure and smoking status • having a stop smoking strategy.
• for 2009/10: CVD primary prevention and sexual health
QOF 2009/10
Primary prevention Disease management Organisational Patient Experience 11
National Audit Office Report on GP contract modernisation Recommendations to the Department of Health
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Develop a long term strategy to support yearly negotiations on the QOF and develop the QOF based on patient needs and in a transparent way
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Base the strategy more on outcomes and cost effectiveness
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Agree to allocate a proportion of QOF indicators for local negotiation at Strategic Health Authority (SHA) or PCT level
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Consider the case for time-limiting QOF points.
Aims and objectives of the new process
• all stakeholders have a clear opportunity to contribute to the development of indicators; • indicators should address topics of importance to patients, professionals and the health of the public and help professionals; • Indicators should address inequalities in health; • indicators proposed for inclusion are based on evidence of clinical and cost effectiveness and make the best use of NHS resources; • there is an objective and transparent system for setting the value of a QOF indicator; • existing indicators are reviewed regularly; • potential new indicators are tested through piloting and considered in terms of whether they are workable; • all processes and methods are inclusive, open, transparent and consistently applied; • there are appropriate governance structures and clear working arrangements with other relevant parties.
Why should NICE lead the process?
• NICE is an independent body with statutory responsibility for providing guidance to the NHS based on evidence of clinical effectiveness and cost effectiveness. The aim is for new QOF indicators to be underpinned by NICE evidence-based clinical and public health recommendations relevant to primary care. • NICE currently has a very high degree of operational independence from the Department of Health and is responsible for developing its methodology and guidance independently.
• NICE already produces guidance aimed at general practice. It has a well established track record in producing evidence-based guidance and consults widely.
• Asking NICE to manage the new process will build on the excellent work of the current QOF expert panel, whilst also ensuring that the assessment of evidence is clearly seen to be independent of the subsequent process for negotiating and approving changes to the QOF. • NICE’s guidance is based on a rigorous assessment of the best available evidence and involves wide consultation with stakeholders and an independent appeals process.
Proposed scope and frequency of review ‘flu indicators Advice from JCVI Indicators out of scope Organisational indicators RCGP practice accreditation Indicators within scope Disease management and secondary prevention (excluding flu indicators) Patient experience indicators GP patient survey Primary prevention and health inequalities Frequency of output for indicators managed by NICE:
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to review all 88 indicators in 3-4 years (20-30 per year)
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cost effectiveness evidence for an additional 10 indicators per year
High-level Timeline and Process Chart
2008 NICE takes over process and appoints panel 2009 Oct Dec Jan Mar Apr Jun Jul - Sep
GOVERNANCE ARRANGEMENTS
DH consultation Government response Oct Dec Jan Mar Apr - Jun 2010 Jul - Sep Oct Dec 2011 Jan Mar
DH
Apr - Jun
NICE EXTERNAL CONTRACTOR PRIMARY CARE PANEL NHS E / GPC INDICATORS FOR 2010/11
Prioritisation Appraisal Recommendations Negotiations SFE in force Changes to contract IT changes
INDICATORS FOR 2011/12
Prioritisation Recommendations Development Piloting Consult Recommendations Negotiations Changes to contract SFE
in force
IT changes
Local flexibility Rationale for local indicators
There may be a high prevalence of certain diseases within a PCT that is not representative of the general population - eg HIV in Southwark, London
Current barriers to uptake
•need for technical expertise in the development of evidence based indicators; •IM&T support required to extract data from clinical systems and to link this with payment calculations. •no national decisions to set aside part of the £1 billion national investment in QOF for local investment.
Solution Menu of QOF indicators ______ ______ ______ ______ ______ ______ QOF indicators % for national use % for local use NHS Employers consult GPC
UK collaboration
• Our aim is for a collaborative approach to developing and reviewing indicators across the four UK countries. • Each of the four countries could remain within a UK framework, with local flexibility according to specific health needs.
• NICE is responsible for evidence based guidelines for England, Wales and Northern Ireland. • There is already good collaboration between NICE and NHS Quality Improvement Scotland. In the future, NICE could use guidance developed from other sources, including SIGN guidance, subject to the availability of cost effectiveness information.
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Responding to the consultation
Quality Team, Primary Medical Care, Room 2E56, Quarry House, Quarry Hill, Leeds LS2 7UE http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_089778
National QOF Consultation
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Tuesday 6 th January, Birmingham
Outline Process for Developing Indicators
Dr Gillian Leng, Chief Operating Officer for NHS Evidence and Deputy Chief Executive, National Institute of Clinical Excellence
Outline of process for developing indicators for the Quality and Outcomes Framework National Institute for Health and Clinical Excellence (NICE)
NSR Prevention Workforce Primary Community Care Strategy Informatics Payment System Leadership Innovation Quality Quality Metrics Quality Accounts Regional Structures Role of NICE National Quality Board Delivering against Measure the quality of patient care Publish the quality of patient care performance Raise the quality of patient care
NHS NSR Final Report
Expanded role for NICE
• Response to ‘the Darzi Review’ – More/faster TAs – Devices and diagnostics – NICE Fellows – More Clinical Guidelines/Public Health guidance – National Quality Standards – NHS Evidence – Quality and Outcomes Framework
Core principles for development of NICE products
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Comprehensive evidence base
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Expert input
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Patient and carer involvement
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Independent advisory Committees
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Genuine consultation and contestability
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Regular review
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Open and transparent process
24 M O N T H S QOF proposed process NICE website suggestions on potential clinical priorities relevant to QOF Collation of NICE evidence based recommendations relevant to primary care Information on current indicators/uptake Primary care consideration panel (PCP) - twice per year - prioritise clinical areas for indicator development and potential inclusion in QOF according to agreed prioritisation criteria.
Panel also consider number of indicators, balance of clinical areas and priorities Stage 1 – Collation of information Managed by NICE Stage 2 – Prioritisation Managed by NICE Collation and prioritisation of evidence based clinical recs.
Stakeholder Consultation Indicator development Six month pilot phase Output Templates Stage 3 – Development Managed through an external contract bar the consultation Indicator development and pilot process PCP - for validation Guidance Executive Publish NHS Employers consult with GPC on QOF changes DH consult GPC on wording of directions Publication of changes to QOF SFE Stage 4 – Validation and publication Managed by NICE, inc consultation Validation and publication Stage 5 – QOF changes
Process for developing indicators
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Stage 1 – Collation of information
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NICE website suggestions on potential clinical priorities relevant to QOF
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Collation of evidence based recommendations relevant to primary care
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Information on current indicators uptake
Process for developing indicators
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Stage 2 – Prioritisation of areas for indicator development - Prioritisation of new areas for the development of indicators and process for dealing with current indicators - Primary Care Consideration Panel will meet twice a year - Decisions made using prioritisation criteria - Panel consider numbers of indicators, balance of clinical areas and priorities.
Primary Care Consideration Panel
• Chaired by an acknowledged expert in primary medical care • Formal Advisory Body status • Meet twice a year • Approximately 30 individuals • Range of experts and representatives of primary care workforce – GPs, patients or carers, commissioners, practice nurses social care professionals from countries taking part and health economists and information specialists
Process for developing indicators
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Stage 3 – Indicator Development (managed through external contract bar consultation step) - New indicators developed
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Current indicators reviewed and cost effectiveness methodology applied - Piloting of indicators - External stakeholder consultation run by NICE
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Assessing cost effectiveness General principles
An indicator is cost effective where net benefit >0 Net benefit = (monetised benefit – delivery cost) – QOF payment Delivery cost
is the cost to deliver the treatment/intervention offset by any savings where new treatments replace older treatments
Monetised benefit
is derived from the expected increase in quality adjusted life year (QALY). NICE will need to identify an appropriate QALY threshold cost, which is expected to be within the range £20,000 £30,000
QOF payment
is an initial incentive to embed within general practice best evidence-based care that will continue to improve patients’ care and health
Process for developing indicators
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Stage 4 – Validation and Publication - Validation and publication of outputs via NICE website
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Menu of new indicators and information about current indicators
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Recommendations about review dates Potential upper and lower thresholds Assessment of evidence on cost-effectiveness to inform decisions on the value of indicators
Process for developing indicators
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Stage 5 – QOF changes
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Indicators published on NICE website fed into DH for negotiation
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NHS Employers consult with General Practice Committee (GPC) on QOF changes - DH consult with GPC on wording of directions
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Publication of changes to QOF Statement of Financial Entitlements
Next steps
• Tender process for external contractor currently running – At consultation events, a record of questions is being kept and will be communicated to all interested parties as part of the tender procedure – Should anyone be considering bidding, any discussion in response to the questions raised at the events will not constitute the office tender view • Timelines – Offers submitted by 6 th February 2009 – Interviews to be held between 9-13 th March 2009 – Contract to be in place by the start of April 2009
Next steps
• Recruiting to Primary Care Consideration Panel early 2009 • Setting up internal project management structures • Proposed process for indicator development will be subject to consultation in 2009
National QOF Consultation
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Tuesday 6 th January, Birmingham
Panel Q & A
Please wait for a microphone before asking your question
Please state your name and organisation
Please keep your questions in the context of the Consultation
National QOF Consultation
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Tuesday 6 th January, Birmingham
Workshop Briefing
Refreshments
Please be ready to start Workshop Session One at 12.00
Workshop Sessions
Criteria for selection process
Room: Orchid
QOF cost effectiveness methodology
Room: Palm Room
Draft selection criteria for areas for developing indicators for the quality and outcomes framework Remit
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Is the proposed topic within NICE’s remit?
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Has NICE already provided guidance or is NICE developing guidance on the proposed topic?
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Is the topic one where GPs can have a significant contribution to make in terms of improving patients’ health?
Health improvement and reduction of health inequalities
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Do the proposed indicators relate to an NHS clinical priority areas, or to other 2.
health-related government priorities?
Do the proposed indicators address an area of action where introduction of 3.
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5.
evidence-based indicators in primary medical care would lead to cost effective improvements in the delivery of health care? Are the consequences understood? Are the costs for other sectors proportionate? Are they affordable and deliverable in the short term?
For public health topics, do the indicators address an area of public health action that promotes population health?
For clinical topics, do the indicators address a condition which is associated with significant morbidity or mortality?
Draft selection criteria for areas for developing indicators for the quality and outcomes framework Effect of intervention
Do the indicators: 1.
significantly improve patients’ or carers’ quality of life; and/or 2.
reduce avoidable morbidity; and/or 3.
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reduce avoidable premature mortality; and/or reduce inequalities in health relative to current standard practice if used more extensively or more appropriately?
Timeliness
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Is this an area of QOF where existing indicators are coming up for review?
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Would new indicators support implementation of new NICE guidance or National Service Frameworks which are in development or recently published?
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Is there emerging evidence for developing new indicators with direct health benefit where there are currently no indicators or where existing indicators do not measure direct health benefit?
Is there a degree of urgency for introducing indicators caused by factors other 5.
than those listed above, for example, significant public concern, a new disease, an important new area for public health action?
Would the indicators still be relevant and timely at the expected date of use?
National QOF Consultation
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Tuesday 6 th January, Birmingham
Feedback, Other Issues & Next Steps
Graham Urwin, Chief Executive, Stoke on Trent PCT
Event Close
• Thank you for attending • Please remember to hand in your delegate badge for recycling
Developing the Quality and Outcomes Framework: Proposals for a new, independent process
Responding to the consultation
Quality Team, Primary Medical Care, Room 2E56, Quarry House, Quarry Hill, Leeds LS2 7UE http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_089778