The Quality and Outcomes Framework and its effect on pharma

Paul Midgley of the Healthcare Partnership charts the progress of the Quality and Outcomes Framework (QOF) since its inception in April 2004 and speculates on the developments due in April 2008 – plus the effect this initiative has had and will continue to have on the pharma industry.

QOF - theory and practice

The QOF is a complex incentive scheme, devised for primary care practices. It was born in 2003 with the advent of new GMS contract, agreed between the Department of Health and the General Practitioners Committee (GPC) of the British Medical Association (BMA). This contract came into effect from April 1st 2004. The QOF scheme was designed to:
• raise organisational and clinical standards in primary care
• reduce morbidity and mortality in priority disease areas
• improve the patient experience
• develop more services in primary care.

In the QOF, Indicators are used to measure different aspects of performance in each of the Domain Areas. For example, in the Clinical Domains there were originally 76 Indicators across the 10 domains, covering aspects of:

Structure – e.g. is there a disease register in place to identify a subset of the practice population who have a particular diagnosed medical condition? e.g. Coronary Heart Disease (CHD) Process – e.g. is the indicator being measured and an appropriate intervention being made, for what percentage of the relevant population identified in the disease register? e.g. cholesterol levels in the patient’s blood for patients with CHD Outcome – how well is the condition being controlled – across what percentage of the disease register population? e.g. the percentage of patients on the CHD register with a total cholesterol of <5mmol/l.

The QOF consists of four domains totalling 1000 points (was 1050 till April 2006):
• clinical domain (mostly ‘long-term conditions’)
• organisational domain (e.g. medicines management, education and training)
• patient experience domain (including length of appointments and patient feedback)
• additional services (e.g. public health measures including cervical screening).

Full details of the individual indicators within each domain can be obtained from the Healthcare Partnership.

Achievements

In 2004/5 practices in England scored an average of 958 points out of the 1050 maximum – earning a practice with average list size and disease prevalence £74,245. Average scores in Scotland, Wales and Northern Ireland were 971, 949 and 989 respectively. The payment per QOF point was £75 in the first year of the scheme.

The average payment per point rose in 2005/6 to £124.62, so that practices achieving maximum points in 2005/6 were paid £130,830. Average QOF achievement per practice in all UK countries was over 1000 points in 2005/6. Somewhat inevitably, recent headlines have accused GPs of being overpaid and wilfully draining the NHS coffers, as a result of their success with the QOF scheme. Of particular concern was their ‘over performance’ compared to the government’s expectations – practices were expected to achieve no more than 750 points on average in the first year, and the government only allowed for this in its financial calculations. Hence, a 30% overspend on QOF equals greedy GPs in the eyes of the tabloid newspapers. GPs would argue that they have taken on a significant additional workload, now employ more staff and work in a different way, and have delivered a very high performance versus target as requested to meet the objectives stated earlier. Either way, QOF now accounts for roughly 1/3 of practice income, so has become a way of life for most practices.

Patients seem to be happy with the increased level of attention they are getting, and liken QOF to an annual health MOT. It’s too early to be sure if morbidity and mortality have dropped since 2004 in the QOF focus disease areas but it would be reasonable to speculate that this will be the case.

QOF’s impact on the market – general practice and pharma

Clearly, if we use the example of the CHD indicators for measuring total cholesterol, this and other similar outcome measures have encouraged practices to treat more patients to the specified targets. In this case, the result has been in an increase in the prescribing of statins, which now account for an annual expenditure of over £600M/annum in the UK.

QOF targets largely reflect existing guidance, e.g. the CHD NSF, and, as a result, will change from time to time as guidance changes. With the added financial incentive that QOF brings, once a national guideline target appears in the QOF scheme, patients diagnosed with these conditions are much more likely to be treated with vigour by most practices, thereby leading to more aggressive treatment of specific medical conditions measured in the QOF. The government has hit on a magic formula – true ‘payment by results’ for General Practice. As the old saying goes, ‘what gets measured gets done.’

In addition, the QOF rewards practices with more money per point depending on the prevalence of QOFspecific conditions in their patient population. This is to take account of the extra workload associated with treating a larger population of patients in areas of high disease incidence – e.g. practices on the coast with a high elderly population will have a larger proportion of patients with a number of the cardiovascular diseases, requiring more work to treat them according to QOF requirements compared to a suburban practice with a predominantly younger, working families population. A side effect of this ‘prevalence factor’ is that patients with a previously hidden disease are now being rooted out and diagnosed, so many practice disease registers are growing – as is the market size for many products used to treat patients targeted in the QOF domains.

We can see this in the figures above, which measure the prevalence of each of the QOF disease domains over the first two years of the QOF scheme.

Between 2004 and 2006, the average number of patients with chronic diseases picked up on a practice QOF disease register rose by about 100 patients per practice.

QOF changes 2006-7

In April 2006, major changes were introduced to mark the third year of QOF. The emphasis on using QOF to develop better management of long-term conditions was increased, with an additional eight new disease domains added to the existing 10, making 18 in total. These 18 clinical domains now account for two/three of all the points in the QOF scheme, which is now worth 1000 points. The recently introduced domains cover patients with:
• atrial fibrillation (includes treatment with anti-coagulant/anti-platelet agents)
• depression (identifying CHD & diabetic patients with co-morbid depression)
• chronic kidney disease (treating their hypertension with ACE/A2A)
• palliative care needs
• dementia
• learning disabilities
• obesity
• smokers.

Chronic kidney disease and depression are common conditions, and many practices now have a significantly increased workload, recognising and managing more patients with these conditions to the new QOF standards and using more drugs to reach the QOF targets.

QOF 2008-9 – more changes await

At the time of writing, the QOF assessment committee is still taking submissions from interested parties who wish to have their nominations considered for inclusion in the revised QOF, due for launch in April 2008. It is expected that the number of clinical domains will increase further in the new QOF. Here are some educated guesses based on recent NICE guidelines, NSFs and other national guidance:

What does this mean to you?

Keep a close eye on the announcements coming out of the QOF review committee, as there will be news in less than a year about new disease areas targeted in the revised QOF, which will once again focus practices to manage certain additional patient groups more vigorously in line with new targets.

In the meantime, if your product is indicated in one of the most recently introduced eight clinical domains, make sure you have QOF conversations within each of your target practices with the following individuals, to ensure your brand is being considered/used appropriately to allow the maximum number of patients to be treated to target:
• lead clinician for the relevant QOF disease domain (may be a GP or a practice nurse – even a counsellor for the mental health/depression domains)
• practice manager (or overall QOF lead for the practice if not the PM)
• individual clinicians/prescribers, if there is no established protocol agreed between the clinicians for managing the specific condition you are promoting into, or if the protocol is not being followed/understood.

Remember disease prevalence – practices may be interested in any audit services you are able to provide which could uncover more patients with QOF-specific conditions thereby increasing their disease prevalence and the money they can earn by treating these patients appropriately.

Finally, make the link between QOF and the local practice-based commissioning plans. Many PBC ‘clusters’ are focusing on developing more capacity for treating patients with common longterm conditions in the community, with the double benefit of reducing the need for hospital admissions (saving money against their PBC budgets and improving their management of QOF conditions, thereby increasing their QOF points achievement.

Ask the question – ‘how can I help your practice manage long-term conditions more effectively?’ – and you are sure to find out that there are areas where you could get involved yourself, or via your NHS development colleagues. It’s now time for the PBC plans to be updated for 2007-8, so start asking questions if you know that your disease area is a local priority and in QOF but is under treated – it could become a PBC priority too with your help, and be more likely to get widespread agreement about best practice and thereby increase your business.