National QOF Consultation

National QOF Consultation Developing the Quality and Outcomes Framework: Proposals for a new, independent process Tuesday 6th January, Birmingham

Welcome & Introduction Graham Urwin, Chief Executive, Stoke on Trent PCT

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 • Raising standards • Stronger involvement of clinicians in decision making at every level of the NHS • Fostering a pioneering NHS • Help to stay healthy • Empowering patients • Most effective treatments for all • Keeping patients as safe as possible Quality at the heart of the NHS High quality care for all • Empowering frontline staff to lead change that improves quality for patients • Valuing the work of NHS staff High quality care for patients and the public Freedom to focus on quality

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. GPs are ahead of family doctors in comparator countries in uptake of financial incentives for quality, IT use and chronic disease management 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 • Average levels of achievement have increased over the three years of the QOF, and variation in achievement has diminished. • In year 1, lower levels of achievement were associated with increased levels of deprivation and variation in achievement between practices increased with deprivation. • 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 • The rate at which quality was improving increased for asthma and diabetes immediately following the introduction of the scheme • The rate of improvement continued for coronary heart disease at the same rate as before the scheme • In subsequent years, the rate of quality improvement appears to have slowed down • QOF needs to be continually reviewed in order to support optimum health outcomes for patients Source: Campbell SM et al; National Primary Care Research and Development Centre

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. 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. Everyday activity • 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 Prevention points Mostly disease management 11

National Audit Office Report on GP contract modernisationRecommendations to the Department of Health • 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 • Base the strategy more on outcomes and cost effectiveness • Agree to allocate a proportion of QOF indicators for local negotiation at Strategic Health Authority (SHA) or PCT level • 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.

‘flu indicators Advice from JCVI • Frequency of output for indicators managed by NICE: • to review all 88 indicators in 3-4 years (20-30 per year) • cost effectiveness evidence for an additional 10 indicators per year Proposed scope and frequency of review Indicators out of scope Indicators within scope Organisational indicators RCGP practice accreditation Disease management and secondary prevention (excluding flu indicators) Patient experience indicators GP patient survey Primary prevention and health inequalities

SFE in force SFE in force High-level Timeline and Process Chart 2008 2009 2010 2011 Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Jul - Sep Oct - Dec Jan - Mar Apr - Jun Government response GOVERNANCE ARRANGEMENTS DH DH consultation NICE NICE takes over process and appoints panel EXTERNAL CONTRACTOR PRIMARY CARE PANEL NHS E / GPC INDICATORS FOR 2010/11 Prioritisation Recommendations Appraisal Changes to contract Negotiations IT changes INDICATORS FOR 2011/12 Recommendations Prioritisation Recommendations Development Piloting Changes to contract Consult Negotiations IT changes

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. Current barriers to uptake QOF indicators % for national use % for local use Menu of QOF indicators ______ ______ ______ ______ ______ ______ Local flexibility 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 Rationale for local indicators Solution 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 processResponding to the consultation QOFConsultation@dh.gsi.gov.uk Quality Team, Primary Medical Care, Room 2E56, Quarry House, Quarry Hill, Leeds LS2 7UE http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_089778

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 Primary Community Payment Constitution Prevention Innovation System Care Strategy Leadership Workforce Informatics Quality Measure the quality of patient Quality care Metrics Quality Delivering against Accounts Publish the quality of patient care performance Regional Structures Raise the quality of patient care Role of NICE National Quality Board NHS 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 • Comprehensive evidence base • Expert input • Patient and carer involvement • Independent advisory Committees • Genuine consultation and contestability • Regular review • Open and transparent process

24 M O N T H S Stage 5 – QOF changes Stage 1 – Collation of information Managed by NICE NICE website suggestions on potential clinical priorities relevant to QOF Information on current indicators/uptake Collation of NICE evidence based recommendations relevant to primary care 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 2 – Prioritisation Managed by NICE Collation and prioritisation of evidence based clinical recs. Stage 3 – Development Managed through an external contract bar the consultation Indicator development and pilot process Indicator development Stakeholder Consultation Six month pilot phase Output Templates Stage 4 – Validation and publication Managed by NICE, inc consultation Validation and publication 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 QOF proposed process

Process for developing indicators • Stage 1 – Collation of information • NICE website suggestions on potential clinical • priorities relevant to QOF MANAGED BY NICE • Collation of evidence based recommendations • relevant to primary care • Information on current indicators uptake

Process for developing indicators • Stage 2 – Prioritisation of areas for indicator development - Prioritisation of new areas for the development of indicators and process for dealing with current indicators MANAGED BY NICE - 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 • Stage 3 – Indicator Development (managed through external contract bar consultation step) - New indicators developed MANAGED EXTERNALLY • Current indicators reviewed and cost effectiveness • methodology applied - Piloting of indicators - External stakeholder consultation run by NICE

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 • Stage 4 – Validation and Publication - Validation and publication of outputs via NICE website MANAGED BY NICE • Menu of new indicators and information • about current indicators • 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 • Stage 5 – QOF changes • Indicators published on NICE website fed into • DH for negotiation MANAGED BY DH • NHS Employers consult with • General Practice Committee (GPC) on QOF changes - DH consult with GPC on wording of directions • 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 6th February 2009 • Interviews to be held between 9-13th 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

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

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 • Is the proposed topic within NICE’s remit? • Has NICE already provided guidance or is NICE developing guidance on the proposed topic? • 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 • Do the proposed indicators relate to an NHS clinical priority areas, or to other health-related government priorities? • Do the proposed indicators address an area of action where introduction of 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: • significantly improve patients’ or carers’ quality of life; and/or • reduce avoidable morbidity; and/or • reduce avoidable premature mortality; and/or • reduce inequalities in health relative to current standard practice if used more extensively or more appropriately? • Timeliness • Is this an area of QOF where existing indicators are coming up for review? • Would new indicators support implementation of new NICE guidance or National Service Frameworks which are in development or recently published? • 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 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?

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 processResponding to the consultation QOFConsultation@dh.gsi.gov.uk 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