What happens when pay for performance stops?
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1413 (Published 10 February 2014) Cite this as: BMJ 2014;348:g1413
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Guthrie and Morales conclude that the 2014/15 QOF contract decision in England to remove incentivised measurement of body mass index, cholesterol and glucose/HbA1c could harm the healthcare provided to those with severe mental illness [1]. These concerns appear not to trouble the English QOF negotiators, who also ignored the QOF Advisory Committee of NICE advising these indicators should be retained as they helped to improve health inequalities for people with severe mental illness[2].
The decision to retire these indicators will limit opportunities in primary care to address cardiovascular disease (CVD) risk in people with severe mental health problems, the single largest contributor to a 15-20 year reduced life expectancy in such patients, despite good evidence that the QOF can improve cardiometabolic risk for this population, albeit less effectively than for those with diabetes [3].
Nor is premature death the only concern. The impact of serious mental illness is amplified by the development of obesity, type 2 diabetes and CVD. Table 1 summarises the scale of risk and the opportunities for targeted prevention.
Systematic monitoring of the dismissed indicators provides the bedrock for prevention activities, and early detection of these disorders in patients with severe mental health problems.
The prevalence of metabolic syndrome, predictive of future diabetes, CVD and premature death, for those at the onset of psychosis is similar to the general population [5]. However, by age forty, metabolic syndrome becomes four times more likely than in non-psychiatric populations [6], highlighting how potentially modifiable cardiometabolic risk builds to create a diverging pathway towards multiple morbidities and premature death for those with severe mental illness. For example within 10-15 years of developing schizophrenia, in a group not known to have diabetes previously, systematic screening found 10% already had type 2 diabetes and another 38% were at 'high risk of diabetes' biochemically [7].
One possible justification for QOF indicator retirement is that they have become embedded in routine practice. The National Audit of Schizophrenia (2012), using standards derived from NICE schizophrenia guidelines [8] revealed only 29% of 5091 patients, under community mental health teams from across England and Wales, had record of an adequate assessment of cardiometabolic risk within the previous 12months (weight, smoking status, glucose, lipids, BP) [9]. Weight was unrecorded in 43%. This emphasises the important role primary care has in filling this gap – but this work may not be done when the indicators go.
Notwithstanding concerns over health inequalities and these dismissed indicators being strongly recommended in NICE guidance [8] this QOF disinvestment contradicts the government’s repeatedly stated policy commitment to reducing the 15-20 year mortality gap for this population.[11] Furthermore delegating QOF negotiating responsibility to the NHS Employers (trading subsidiary of the NHS Confederation) would indicate the government values the charitable status of an organisation whose stated purpose is simply described to the Charity Commission:
“The Charity’s objects are the relief of sickness and the preservation and protection of public health”
Objects 4.1 Memorandum and Articles of Association of the NHS Confederation[12]
Guthrie and Morales’ conclusions reinforce the NICE QOF advisory committee’s position and appear at odds with this charity’s declared commitment to preservation and protection of the public health.
The late Professor Lester, leading general practitioner and academic advising on the QOF until her death a year ago, pointed to discrimination as the critical explanation of why this population experience poor healthcare. In the James McKenzie lecture Being Bothered about Billy [13] Professor Lester reminded colleagues from the Royal College of General Practitioners of the poor access and discrimination that Billy and others too often face in primary care. She challenged her colleagues to embrace prevention ‘Don’t just screen, intervene’. She reminded us that much of this is not rocket science; that primary care is ideally placed to improve the health and health outcomes of this population; and that the healthcare of people with serious mental illness is our business.
As Guthrie and Morales highlight, this QOF decision may have made helping Billy just a bit more difficult in England.
Dr David Shiers MB ChB, MRCGP, MRCP (UK), Clinical advisor to National Audit of Schizophrenia, retired GP North Staffordshire, carer of daughter with schizophrenia
Professor Carolyn Chew Graham MD FRCGP, GP Manchester, Professor of General Practice Research, Keele University, and RCGP Curriculum Guardian, Mental Health
Correspondence david.shiers@doctors.org.uk
Declaration of interests
CCG is a member of the project reference group for the NICE multimorbidity guidelines.
DS is a current member of the Guideline Development Group for NICE guidance for adults with psychosis and schizophrenia, member of NCCMH board, and received a lecturing honorarium from Janssen in September 22nd 2010
References
1. Guthrie B, Monales DR. What happens when pay for performance stops? BMJ 2014; 348: g1413.
2.NICE Primary Care Quality and Outcomes Framework Indicator Advisory Committee Minutes of extraordinary meeting Sept 18th 2013
http://www.nice.org.uk/aboutnice/qof/PrimaryCareQOFIndicatorAdvisoryComm...
3. Mitchell AJ, Hardy SA. Screening for metabolic risk among patients with severe mental illness and diabetes: a national comparison. Psychiatr Serv. 2013;64:1060-3.
4 De Hert M, Dekker JM, Wood D, et al. Cardiovascular disease and diabetes in people with severe mental illness. Position statement from the European Psychiatric Association. Eur Psychiatry 2009; 24: 412-424. http://www.easd.org/easdwebfiles/statements/EPA.pdf
5. Fleischhacker WW, Siu CO, Bode R, Pappadopulos E, Karayal ON, Kahn RS, and the EUFEST study group Metabolic risk factors in first-episode schizophrenia: baseline prevalence and course analysed from the European First-Episode Schizophrenia Trial. Int J Neuropsychopharmacol. 2013; 16:987-95.
6. Saari KM, Lindeman SM, Viilo KM, Isohanni MK, Jarvelin MR, Lauren LH, et al. A 4-fold risk of metabolic syndrome in patients with schizophrenia: the Northern Finland 1966 Birth Cohort study. J Clin Psychiatry. 2005;66:559-63.
7. Manu P, Correll C, van Winkel R, et al, Prediabetes in Patients Treated With Antipsychotic Drugs J Clin Psychiatry. 2012; 73:460-6
8. NICE (2009) Schizophrenia: Recommendation 10.4.1 of Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. Clinical Guideline 82. London: NICE.
9. Royal College of Psychiatrists. Report of the National Audit of Schizophrenia (NAS) 2012. London: Healthcare Quality Improvement Partnership; 2012.
11. Department of Health (2011) No Health without Mental Health London: Department of Health
12. Section 4.1 Objects; Memorandum and Articles of Association of the NHS Confederation; incorporated on 23 January 2002; Page 2; Company Number 4358614.
13. Lester H.E. Being Bothered about Billy. RCGP James McKenzie Lecture 2012 Brit J of Gen Practice. 2013 608; e232-e234
View article: http://www.ingentaconnect.com/content/rcgp/bjgp/2013/00000063/00000608/a...
View You-tube http://www.rcgp.org.uk/news/2012/november/professor-helen-lesters-presen...
Competing interests: DS: Current member of the Guideline Development Group for NICE guidance for adults with psychosis and schizophrenia; member of NCCMH board; and received a lecturing honorarium from Janssen in September 22nd 2010 CCG: member of the project reference group for the NICE multimorbidity guidelines.
Re: What happens when pay for performance stops?
Guthrie and Morales1 are correct to highlight that radical change is coming to the clinical and public health indicator set of the UK’s Quality and Outcomes Framework (QOF) in 2014/15.2 3 Their editorial, however, only partially explores the roles of the National Institute for Health and Care Excellence (NICE) and NHS England in retiring indicators from QOF, and the implications for patient care.
NICE has managed the process for developing QOF indicators from April 2009.4 In August 2013 NHS England formally asked NICE to review the QOF Clinical and Public Health indicator set to determine which indicators would be the most important to retain in the event that the number of indicators were reduced with a view to using the review to informing the QOF negotiations for 2014/15.5 NICE’s QOF Indicator Advisory Committee met in September 2013 to conduct this review, which involved reviewing all the current QOF clinical and public health indicators against an explicit decision making framework (e.g., strength of evidence supporting the indicator; whether working as intended; workload for practices).5 The committee considered that it was important to retain the majority of the clinical indicator set (90%, 84/93) and only identified a minority (23%, 26/111) of indicators, chiefly those in the public health additional services domain (cervical screening; child health surveillance; maternity and sexual health), as being less important to retain.5 In the negotiation process, however, more radical changes were made to QOF than was advised by NICE: in November 2013 NHS England announced a set of major changes to QOF for 2014/15.2 In the light of such changes questions do need to be asked as to whether the QOF will survive in its current form given its cost and limited evidence of effectiveness as a quality improvement strategy.6
The key changes to QOF in the clinical and public health domains for 2014-15 are: the retirement of 24 indicators from the clinical domain releasing 185 points and the retirement of six indicators from the public health domain releasing 33 points (Table 1).
The changes are worthy of two general reflections. The first, as noted by Guthrie and Morales1 is that all financial incentivisation has been removed from the majority (88%, 21/24) of the retired clinical indicators, with no mandatory requirement for the NHS to continue to monitor the effects on patient care through the collection of routine data. Thus there is no financial incentive to monitor the physical health of people with serious mental illness or do any care processes or measure health outcomes for people with epilepsy. Although NHS England has said that “we intended to continue to collect and publish data, as far as possible, on the relevant interventions and outcomes in order to support practices in promoting ongoing quality improvement”2 further detail is required on the collection and publication of such data. It will be important that the impact of these changes is monitored with routinely collected data, as it cannot be assumed that they will not adversely impact on patient care.
The second reflection is that many of the changes seem inconsistent (e.g., the lipid target indicator for people with diabetes is retained, whilst it is retired for people with established CVD). Unlike NICE’s role in the QOF process, the rationale for the negotiator’s decisions is not in the public domain, and the negotiators have gone further than the advice they received from NICE. The majority of retirements (53%, 16/30) are recently developed indicators using the NICE indicator development process (2011/12 QOF or later). It is a concern that recently developed indicators, particularly those introduced only a year ago in 2013/14, are now being retired as these are still likely to represent quality improvement as they are less likely to have become embedded into routine practice. Furthermore, the majority of retirements (53%, 16/30) were those which NICE’s advisory committee felt were important to retain. The fact that the negotiators chose not to accept NICE’s advice in full must also raise questions as to the future impact of NICE in further developing the QOF, and the resulting loss of public accountability in the decision-making process.
Dr Tim Stokes
Senior Clinical Lecturer in Primary Care
School of Health and Population Sciences
University of Birmingham, UK
Dr Nick Steel
Clinical Senior Lecturer in Primary Care, Norwich Medical School,
University of East Anglia, UK
References
1. Guthrie B, Morales DM. What happens when pay for performance stops. BMJ 2014:348:g1413.
2. NHS England. 2014/15 GMS Contract Negotiations. 15 November 2013. Gateway Reference 00698. Available at: http://www.england.nhs.uk/wp-content/uploads/2013/11/gms-contr-let-at113...
3. British Medical Association. NHS England. NHS Employers. 2014/15 General Medical Services (GMS) Contract Quality and Outcomes Framework (QOF) Guidance for GMS contract 2014/15. NHS Gateway reference 01624. Available at: http://www.nhsemployers.org/Aboutus/Publications/Documents/2014-15-QOF-g...
4. Sutcliffe D, Lester H, Hutton J, Stokes T. NICE and the Quality and Outcomes Framework (QOF) 2009-2011. Quality in Primary Care, 2012; 20:47-55.
5. National Institute for Health and Care Excellence (NICE). Quality and Outcomes Framework (QOF) Indicator Development Programme: Indicator Assessment Report. 18th September 2013. Available at: http://www.nice.org.uk/media/9CD/26/QOFIndicatorAssessment_ReportSeptemb...
6. Gillam SJ, Siriwardena AN, Steel N. Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review. Ann Fam Med 2012; 10(5):461-468.
Competing interests: Tim Stokes was Consultant Clinical Adviser to NICE on its QOF work programme 2009-2013. Nick Steel was a member of NICE's QOF Indicator Advisory Committee 2009-2012.