The Quality and Outcomes Framework (QOF)
QOF is the annual reward and incentive programme detailing GP practice achievement results.
QOF is a voluntary process for all surgeries in England and was introduced as part of the GP contract in 2004.
QOF awards surgeries achievement points for:
- Managing some of the most common chronic diseases, e.g. asthma, diabetes;
- Implementing preventative measures, e.g. regular blood pressure checks;
- The extra services offered such as child health care and maternity services;
- The quality and productivity of the service, including the avoidance of emergency admissions to hospital;
- Compliance with the minimum time a GP should spend with each patient at each appointment.
When QOF was first introduced as part of the GMS contract in 2004, the following principles were agreed on where QOF standards should apply:
- Responsibility for on going management of the patient rests primarily with the GP and the primary care team;
- There is evidence of health benefits resulting from improved primary care;
- The disease is a priority in a number of the four nations.
19.1 QOF domains and indicators
The QOF has a range of national quality standards, based on the best available, research-based evidence covering four domains. Each domain has measures of achievement, known as indicators, against which practices score points according to their level of achievement. Practice payments are calculated on the points achieved and prevalence (see prevalence below).
The four domains are:
The above domain has indicators across different clinical areas e.g. coronary heart disease, heart failure, and hypertension.
The above has indicators across the five areas of records and information, information for patients, education and training, practice management, medicines’ management and quality and productivity. It requires practices to hold policy information and have processes in place that actively demonstrate sound practice and understanding amongst their practice team.
Patient experience –
The above has an indicator on the length of patient consultations.
The above has indicators across the four service areas of cervical screening, child health surveillance, maternity services and contraceptive services.
However, the Ministers have tinkered with QOF domains, indicators and payments continually and they are a shadow of what they were originally.
As part of the 2014/15 GMS contract changes, NHS Employers and the General Practitioners Committee (GPC) of the BMA agreed a number of changes to QOF effective from 1 April 2014.
The key changes were:
- The retirement of 24 indicators from the clinical domain releasing 185 points (three points released from retirement of LD002 will transfer to the learning disability enhanced service funding);
- The retirement of six indicators from the public health domain releasing 33 points;
- The retirement of the patient experience indictor PE001 releasing 33 points;
- The retirement of nine indictors from the quality and productivity domain releasing 100 points.
Of the above retirements, the resource from 238 points will be transferred in to global sum. This funding will not be subject to the six per cent out of hour’s deduction (if applicable).
The resource released from the remaining 103 points will see 100 points used to fund a new enhanced service aimed at avoiding unplanned admissions and delivering proactive case management for vulnerable people and 3 points transferred to the learning disabilities enhanced service.
http://bma.org.uk – tabulation of Indicators with description and points are well elucidated on this web site.
QOF for 2015-16 – changes proposed was being under negotiation (see NICE web site).
For 2012/13, there was a maximum of 1,000 points available to practices across QOF, which in turn determine payments. The key payment dates for each year:
- By 31 March – practices are paid retrospectively for points achieved in the previous year. The pounds per point for 2012/13 for England – £133.76. The value of a QOF point differs across Wales, Scotland and Northern Ireland.
- By the end of June – payments should be completed, although they can be made earlier when they have been agreed by the practice and the primary care organisation.
Payments are subject to certain thresholds (targets) and take account of the national prevalence of diseases, by applying a standard calculation to all practices.
A practice’s achievement payments are based on the number of patients on each disease register, known as ‘recorded disease prevalence’. In certain cases, practices can exclude patients – known as ‘exception reporting’. Strict criteria are used for this process and practices may be required to provide evidence of any patient that is ‘exception reported’.
QOF clinical indicators 2012/13: summary tables
The quality and outcomes framework of the GMS contract 2012/13 came into effect on 1 April 2012. The details can be accessed via website of BMA, NHS, NICE etc. The clinical domain covers the following areas:
- 45 points Asthma;
- 27 Atrial fibrillation (AF);
- 11 Cancer;
- 13 Cardiovascular Disease (primary prevention)
- 69 Coronary Heart Disease (secondary prevention) (CHD);
- 36 Chronic kidney Disease (CKD);
- 30 Chronic Obstructive Pulmonary Disease (COPD);
- 10 Contraception (SH);
- 26 Dementia (DEM);
- 31 Depression (DEP);
- 88 Diabetes Mellitus (DM);
- 14 Epilepsy;
- 29 Heart Failure (HF);
- 69 Hypertension (BP);
- 7 Hypothyroidism (THYROID);
- 7 Learning Disabilities (LD);
- 40 Mental Health (MH);
- 8 Obesity (OB);
- 9 Osteoporosis (secondary prevention of fragility
- 6 Palliative care (PC);
- 9 Peripheral arterial disease (PAD);
- 73 Smoking; and
- 22 Stroke and transient ischaemic attack (Stroke);
- 36 Medicines Management (Medicines);
- 5 Quality and Productivity (QP).
814.5 Total Points.
Each disease area has a series of evidence-based indicators.
Points are attached to each indicator and determine the sum paid to each practice.
The tables would indicate the following:
Amendments due to:
- Increased threshold
- Replacing previous indicator
- Reducing points
- New indicator.
QOF has seen evidence based indicators achieved by almost every GP practice in the UK to a very high level. The QOF has delivered benefits to patients through the improved monitoring and treatment of acute and chronic health problems. The coordinated and comprehensive care patterns supported by the QOF have also helped to reduce inequalities across the UK.
Through the QOF, general practices are rewarded financially for aspects of the quality of care they provide. QMAS ensures consistency in the calculation of quality achievement and disease prevalence, and is linked to payment systems.
The payment rules underpin the new GMS contract are implemented consistently across all systems and all practices in England.
For 2009/10, practices were paid on average, £126.77 for each point they achieved.
The value in pounds per point for 2012/13 for England is £133.76.
Current Indicators for 2014-15:
19.31 QOF Indicators for 2014-15.
Each year Indicators, points and awarded and achievement levels are changed and the above table lists details for 2014-15.
The Table details have been edited to show just the point details only.
Changes are proposed for 2015-16 and discussions are proceeding.
The practices will have all the changes and guidance through CCGs, and publications like PULSE.
Directed enhanced services
Directed enhanced services (DESs) are special services or activities provided by GP practices that have been negotiated nationally. Practices can choose whether or not to provide these services.
Directed enhanced services 2012/13
In 2012/13 the Extended Hours DES was extended by one year, in England, to 31 March 2013. The Patient Participation DES, which was introduced in April 2011 for two years and will continue in 2012/13.
The following existing DESs are to be re-commissioned by PCTs, in England, for the twelve-month period ending on 31 March 2013:
- The alcohol reduction scheme, and
- The learning disabilities health check scheme.
The requirements for these clinical DESs remain the same and the payment scheme will mirror the payment scheme at the same rate that applied for the period 1 April 2011 to 31 March 2012.
19.6 Target Indicators
For meeting targets
There are ample publications and details in websites about the indicators and meeting targets and the steps used in the past in the surgeries worked are mentioned for a few diseases.
19.6.1 Coronary Heart Disease (CHD)
Indicators, including those outside the QOF framework, which are continually reviewed, for better patient management are listed below:
- Call and Recall of patients
- Yearly patient reviews
- Past history of myocardial infarction and CHD
- Angina is clinical diagnosis – should have 12 ECG performed
- A normal ECG does not exclude coronary artery disease
- Newly diagnosed angina patients to be referred to exercise tolerance testing (ETT) myocardial perfusion testing
- Patients not to be referred to ETT if:
- They are on maximal medical treatment and still have angina symptoms
- The diagnosis of CHD is unlikely (refer to cardiologist)
- They are physically incapable of performing the test
- They have clinical features suggestive of aortic stenosis or cardiomyopathy
- The results of stress testing would not affect management
- Alternative to ETT – cardiologist, general physician or GP with special interest
- BP to be measured annually; 150/90 or less is the guideline for control
- Cholesterol annually 5.0 mmol/l or less; for over this value patients should be offered lipid lowering therapy
- Aspirin 75-150 mg/day for CHD. Clopidogrel 75 mg/day for contraindications to aspirin or intolerant of aspirin. Avoid aspirin in patients who are anti-coagulated.
- Beta blockers (unless a contraindication or side effects are recorded) and ACE inhibitors or A2 antagonist (unless contraindicated) to be recorded.
|19.6.2 Hypertension (BP) – MUST DO” CRITERIA These are the absolute minimum criteria that practices need to audit as they have an important impact on outcome and there is firm research evidence to justify their inclusion. Every practice must include these criteria in the audit.|
|1||Patients who have been diagnosed as hypertensive have been recorded in a practice hypertension register.|
|2||The records show that in patients without target organ damage, the blood pressure has been measured at least twice on each of at least three separate occasions prior to commencement of drug therapy.|
|3||The records show that at diagnosis, the following symptoms and signs of target organ damage have been sought: retinopathy, left ventricular hypertrophy, angina, stroke, heart failure, peripheral vascular disease and renal disease.|
|4||The records show that an assessment has been made of the risk factors for cardiovascular and cerebrovascular disease and that if necessary, appropriate advice and treatment has been given: smoking habit, body mass index, diabetes mellitus, serum cholesterol (if additional risk factors present), excessive alcohol intake, physical inactivity and family history of premature coronary artery disease.|
|5||The records show that the mean pre-treatment blood pressure level was at least a diastolic of 95mmHg or greater and/or a systolic of 160mmHg or greater, or a diastolic of 90-95mmHg in the presence of other cardiovascular risk factors, and/or target organ damage.|
|6||The records show that the patient has been reviewed at regular intervals not exceeding 6 months.|
|7||The records show that the hypertension is well controlled, the average of the last three recorded diastolic blood pressure readings being 90mmHg (diastolic) or below, and 160mmHg (systolic) or below.|
|8||The records show that a patient with refractory hypertension and/or suspected secondary hypertension has been referred for specialist advice.|
|“SHOULD DO” CRITERIA These are additional criteria for which there is some research evidence of their importance.|
|9||The records show that at least annually there is an assessment of side effects caused by antihypertensive drugs that the patient is taking.|
|10||The records show that at least annually the patient has been given advice about dietary salt restriction|
The British Heart Foundation
Tel: 08450 708070
- Indicators, including those outside the QOF framework, which are continually reviewed, for better patient management are listed below:
- Call and Recall of patients
- Yearly patient reviews
- Avoid undiagnosed patients with diabetes
- Diagnose diabetes as per WHO 1999 criteria:
- Random glucose test – glucose >11.1 mmol/l – 2 occasions
- Fasting glucose test – >7.0 mmol/l; 12 hr. fasting; 2 occasions
- Glucose tolerance test – >11.1 mmol/l diabetes.
- <7.8 mmol/l normal
- Register to exclude:
- Children age 16 and under with diabetes and under specialist care
- Patients with gestational diabetes
- Because of vascular risks, regular reminders to patients about smoking
- Smoking cessation services help diabetic smokers to quit; referral to clinics should be discussed with patients
- Fructosamine instead of HbA1C – patients with haemoglobinopathies
- HbA1C – stable patients test every 6 months; others more frequently.
- HbA1C target between 6.5% to 7.5% based on the risk of macrovascular and microvascular complications
- Systematic annual screening of all people with diabetes
- Annual review to highlight need for referral for vasculopathy and neuropathy to detect problems with foot.
- Record presence or absence of peripheral pulses annually
- Foot sensation abnormal if monofilament and or vibration sensation impaired – record neuropathy test results
- BP – aim for 140/80
- Diabetic nephropathy greater than 300 mg/day; urine albumin concentration and serum creatinine to be measured at diagnosis and at regular intervals
- Patients with microalbuminuria or proteinuria to be commenced on ACE inhibitor or considered for angiotensin II antagonist therapy
- Cholesterol less than 5.0 mmol/l; for greater value start on Statin therapy.
Diabetes- Clinics requirements for surgeries.
- Initially, the estimated time to see each diabetic patient is about 20 min. Consequently, a maximum of 6 patients needs to be booked for the clinics. PCT Nurse to notify any increases in number to receptionists and practice nurse.
- PCT Nurses – H Grade nurses are able to do the clinic with no involvement of the GP’s except for any discussions pertaining to fine-tuning off medication, it is imperative that their time is utilized more effectively and the preparatory and finishing work is done in-house by the practice nurses and receptionists.
- The protocols for the clinic have been provided by Torex and can be accessed by using Premier, then the patients record, then clicking icon ‘ISIS’ and selecting GMS Diabetes mellitus. The various screens will appear one after another once the details for each screen is input.
- The PCT Nurse will see all diabetic patients in the clinics. The details of insulin dependent patients, who are seen by hospitals and under their monitoring, will be entered in the computer. GP’s roles are to utilize hospital services and follow hospital consultant’s recommendations. (New Contract stipulates what factors to be assessed and reported and does not expect GP’s to do it).
- Blood Test results needed prior to giving appointments to PCT Nurse:
The details required to be determined, and recorded are:
Fasting Lipid Profile
If the details are not available, then a blood test has to be done and results obtained prior to giving clinic appointment with PCT Nurse.
Patients are invited to come and pick up the blood test forms to be taken to the hospital. Practice nurse has to identify such patients and the receptionists have to telephone/contact them to come to surgery and pick up the blood test forms.
Once the results are obtained, then practice nurse has to put the data in the computer ‘ASAP’.
- Urine Sample – all patients to give sample for urine test – to be done on the day (prior to clinic appointment) with PCT Nurse.
- Nurse’s Folder for any referral as required:
The following need to be provided in a folder for the PCT Nurse:
7.1 Referral form for Dietician
7.2 Referral form for Chiropodist
7.3 Referral form for Retinopathy evaluation –
7.4 Diabetic Protocol –PCT Nurse will assist with
proving such a protocol.
Essential equipment and test units:
8.1 Micro-albumin Test strips – need to be
available in the consulting room
8.3 Electronic BP equipment.
Inviting patients – steps to follow by practice nurse:
9.1 Initially patients not seen for over 1 year
9.2 Check whether the patient has had blood test
results with all the relevant details listed in ‘5’ above.
If yes – then make appointment for the PCT Nurse.
If no, then arrange for blood test as stated in ‘5’ above.
9.3 Make a list of patients with name, surname and
DoB and telephone number and give to the
Senior Receptionist to arrange for
appointments with PCT Nurse on the
appropriate dates for the clinic.
9.4 Initially max. 6 patients per clinic (see 1 above).
9.5 Once patients not seen over 1 year have been
called, then patients not seen over 6 months
need to be called (steps 9.2 to 9.4 apply).
- Practice Nurse with GPs will have to assess the monthly performance for the diabetic clinic and make recommendations on improvements so as to meet the set targets and reach quality points predicted.
19.6.4 Mental Health Patient Policy
- Register should be in the folder.
- Patient should be called 3 times at least to attend clinic and should be documented in the note and on computer.
- Copy of calling/recalling letter should be filed in the note and documented on computer.
- If they do not attend clinic/surgery appointment despite requesting to attend, they should be referred to Psychiatric Service informing them that we are concerned and need help – all should be documented in note and on computer.
The new GPs Contract includes mental health among ten clinical areas attracting payment for the achievement of clinical indicators. Studies have shown that one in six people of working age have a mental health problem and that most of these are managed in primary care, only about nine per cent are referred to specialist services for assessment and treatment.
Following this development is the disease registers. The Mental Illness Register is a vital resource for all GP practices. In addition to keeping records of patients identify as having mental health problems, care is better organised around three reviews: medication, physical checks and coordination with secondary care. These can be monitored and audited from computer systems to improve the management of depression, anxiety, schizophrenia, and post-natal depression in both primary and secondary care. In particular lithium toxicity often attributed to drug interactions can be greatly reduced through regular blood test and medication reviews.
In general the register is useful in mapping out care pathways, asking for more resources to manage patients better and to make sure they do not fall through the net.
The Primary Care Mental Health Worker will support the practice to achieve all the points allocated for the management of patients and all the work will be rewarded through the QOF and QMAS.
19.7 Support with Clinical Audit
The Medical Audits Advisory Group (MAAG) recorder is normally used to determine a sample size for Clinical audits that represents the patient population and reflects the clinical activities that took place in the practice/surgery for which an audit is required, particularly audits under the prescribing incentive scheme for antidepressant/antipsychotic drugs, Z drugs etc. PCT will help the surgeries with what the prescribing advisor requires of the surgery and, if necessary, can redesign forms to serve other purposes as well.
19.8 Patient Information
GUIDANCE ON THE CALDICOTT REPORT FOR THE PROTECTION AND USE OF PATIENT INFORMATION – 2001
Recommendations and Principles:
Principle 1 – Justify the purpose.
Principle 2 – Don’t use patient-identifiable information
unless it is absolutely necessary.
Principle 3 – Use the minimum necessary patient-identifiable
Principle 4 – Access to patient-identifiable information
should be on a strict need-to-know basis.
Principle 5 – Everyone with access to patient-identifiable
information should be aware of their
Principle 6 – Understand and comply with the law. Every use
of patient-identifiable information must be
All practices should be aware that the specifications for LES 1, 2 and 3 required practices to be open at reception for both telephone and face to face access for 45 hours a week by the end of May 20.