The Quality & Outcomes

Framework – triumph or

tragedy?

Steve Gillam

26.10.11

On this day…

„Mr Atlee is a very modest man.

Indeed, he has a lot to be modest about.‟

„I‟m just preparing my impromptu remarks.‟

„If this is a blessing, it is certainly very well

disguised.‟

„A pessimist sees the difficulty in every

opportunity; the optimist sees the opportunity in

every difficulty.‟

Outline

Background

Methods

Main findings

Impact of QoF

Implications

Background

International literature on pay for performance (P4P)

Introduced in 2004 in the UK

>£1billion per annum

22% GP income

Largest natural experiment in P4P in the world

Precursor schemes, e.g. PRICCE

Domains for quality indicators in QOF 2010 Clinical

Secondary prevention of coronary heart disease

Cardiovascular disease: primary prevention

Heart failure

Stroke & TIA

Hypertension

Diabetes mellitus

COPD

Epilepsy

Hypothyroid

Cancer

Palliative care

Mental health

Asthma

Dementia

Depression

Chronic kidney disease

Atrial fibrillation

Obesity

Learning disabilities

Smoking

Organisational

Records and information

Information for patients

Education and training

Practice management

Medicines management

Patient experience

Length of consultations

Patient survey (access)

Additional services

Cervical screening

Child health surveillance

Maternity services

Contraception

QOFability – ideal indicator is

Acceptable

Attributable

Feasible

Reliable

Sensitive to change

Of predictive value

Relevant

Systematic review of all published research till end august 2011

Medline, EMBASE, CINAHL, PsycINFO, Health Business Elite, Health Management Information Consortium, British Nursing Index, Econ Lit

575 research papers identified; 124 selected for review

Methods

Main findings

Health care gains

Population health and equity

Cost effectiveness

Impact on providers and teams

Patients‟ experience

Health care gains

Real but modest gains in some areas, e.g. asthma, DM

(?trendlines)

Better recording in QOF areas but not untargeted areas

No definitive improvement in outcomes, except possibly

epilepsy/DM admissions

Doran et al. N Engl J Med 2009;361:368-78.

Population health and equity

Inequalities related to deprivation slowly narrowing

Reductions in age-related differences for CVD/diabetes

Variable effects for e.g. gender related differences in

CHD

Dixon, Khachatryan & Boyce. The public health impact, In Gillam & Siriwardena (eds) The

Quality and Outcomes Framework, Radcliffe, Oxford 2010.

Lancet 2008;

372: 728–36

High risk individual and population based

strategies for prevention (Rose)

Identify and treat

those beyond a

threshold for risk

factor

Shift the whole

population

distribution of risk

factor

QOF scores nationally (% total points) and

changes in exception reporting rates 2004-2009

Limited evidence of ‘gaming’ but

does ER reduce QOF’s impact on

neediest populations?

Costs and effectiveness

No relationship between pay and health gain

Limitations to modeling, e.g. omit costs of

implementation

Cost effectiveness evidence studied for 12 indicators in

the 2006 revised contract with direct therapeutic effect

(Fleetcroft et al). 3 most cost-effective indicators were:

ACEI/ARB for CKD

Anticoagulants for AF and

Beta-blockers for CHD

Costs and effectiveness

Modest mortality reductions modelled - potential saving of 11 lives per 100,000 people per year across all indicators (Fleetcroft et al).

Average indicator payments ranged from £0.63 to £40.61 per patient; the percentage of eligible patients treated ranged from 63% to 90% (Walker et al).

Improvements in performance required for QOF payments to be cost-effective varied by indicator from less than 1% to 20% (Walker et al).

Impact on providers and teams

Changing structures, roles and staff – nurse-led care

Greater use of information technology

Restratification: „chasers‟ and „chased‟

Emphasis on the biomedical

Commodification of care

Narrative of „no change‟

Checkland & Harrison. Impact of QOF on practice organisation and service delivery. SocSciMed, 2008.

„Every day I come in I check (performance)… I‟m a chaser… You have to chase yourself though. You‟ve no credibility if you don‟t deliver.‟

„Some patients will come to you and they‟ll plead with you: „please don‟t give me any tablets, I‟ll bring my bp down, I‟ll do everything…but we‟re saying to them: „well look, we‟ve checked it three times now and it remains raised, you‟re clinically classed as hypertensive, we follow these guidelines and this is what we should be doing with you.‟

„All I think QOF did was make it a bit more organised and that. I don‟t think it was anything new.‟

Checkland & Harrison. Impact of QOF on practice

organisation and delivery. Soc Sci Med, 2008.

Patients’ experience

Little research on patient related/reported impact

Continuity and relationships affected

Fragmentation of care

Little explanation provided to patients “A slim, active 69-year-old patient attending for influenza vaccine

was faced with questions about diet, smoking, exercise and

alcohol consumption. There was no explanation for why these

questions were asked; they seemed irrelevant to having

a „flu vaccine. Blood pressure and weight had to be recorded and

a cholesterol test organised. A short appointment lasted almost

15 minutes without the patient having the opportunity to ask a

question about any aspect of „flu vaccine.”

Summary - QOF balance sheet

Better data recording and analysis

Modest health benefits for individuals and populations

Narrowing of inequalities in processes of health care

Improved team-working

Opportunity costs unknown, e.g. impact on preventive care

Unintended consequences: on workforce, professionalism

Scientific bureaucratic medicine and the McDonaldisation of care

Re-defined meaning of „quality‟

Implications – ways forward

Limit expansion but expand local discretion

Options

Leave indicators unchanged and anticipate higher achievement each year

Add new indicators or conditions

Select from a larger set of evidence-based measures

Remove measures once agreed level achieved

Rotate measures