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.
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.
Rapid Response:
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.