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The waiting game

Quality earnings: your three steps to heaven

In a major new series on the quality and outcomes framework, Dr John Couch looks at the money available and indicates the degree of effort required to earn points under each framework category.

This week ­ coronary heart disease

The quality and outcomes framework element of the new contract forms a large proportion of the promised pay rise for GPs. This will be phased in over the next two years with the largest increase payable from 2005/6.

Anticipation of this extra money is rapidly wearing off as goalposts move almost weekly and the reality of the work involved sets in. And so GPs are asking will it be worth it? The answer is almost certainly Yes, provided practices are careful to spread and target their efforts carefully. The aim of this series is to help practices do just that.

The initial scheme covers 10 chronic diseases, four organisational and two patient experience areas, four additional services and three linked payments (see table right).

Each of the first three items is further divided into several indicators. Finally each indicator carries points, most of which are tiered to allow some money to be earned even at relatively low levels of achievement but progressively more money as performance improves.

The maximum number of points available is 1,050. The pricing of points varies. For the 10 chronic disease areas the average will be based on average disease prevalence. Practices with a higher prevalence of CHD for instance will earn more money per point and

vice-versa. For organisational points the pricing will be based on average list size, probably 1,833 patients per whole-time equivalent GP list for practices opting for the Carr-Hill formula and approximately 1,947 patients for those opting for MPIG. Here a higher-than-average list will produce higher points values and vice-versa.

In 2004/5 one point will be worth on average £25 per GP and for 2005/6 £40. An average maximum of £26,250 and £42,000 per GP will therefore be available for those two years respectively for any practice reaching all 1,050 points. In addition around £3,000 preparation money per GP is being paid in 2003/4 to encourage extra resources to be made available.

Payment of quality and outcomes framework money will be phased. At the beginning of each April, starting this year, practices will predict their points score for that year.

A third of this, the 'aspiration payment', will be paid in monthly instalments during the year, the balance in April or May the following year, adjusted upwards or downwards according to actual performance.

All practices will therefore need to be careful not to be overconfident! Most practices should be able to improve their scores year on year. It is likely that

other disease areas such as depression will be added after 2006.

There is one sting. Ignore the framework and you get penalised. Any practice failing to achieve at least 100 points in 2004/5 and 150 points in 2005/6 will have the equivalent amount of money deducted from their global sum.

PMS practices will also be able to take advantage of the framework but the payment and structure will vary from GMS. The latest news is that PMS practices will have around 200 points deducted and may be able to formulate their own quality indicators.

Planning is vital and should take into account two factors. The indicators have varying levels of achievability and most of them have a tiered structure allowing some payment at achievement levels as low as 25 per cent.

The points can very roughly be subdivided into three bands, which for the purpose of this series we have labelled 'easy', 'middling-hard' and 'hard'.

Easy Those that most practices either already achieve or should easily achieve.

300 points

Value 2004/5 = £7,500 per average GP

2005/6 = £12,000

Middling-hard Those within the reach of well-organised practices.

300 points

Value 2004/5 = £7,500 per average GP

2005/6 = £12,000

Hard The most difficult points where the cost benefit of striving for top marks must be carefully gauged for each indicator.

450 points

Value 2004/5 = £11,250 per average GP

2005/6 = £18,000

Practices have until 31/3/05 for their first official points deadline. It makes most sense to consolidate the easy and middling-hard levels first as these will involve less work and expense. This does not mean the 'hard' levels should be ignored as low achievement in year one will still attract points and most of the hard indicators carry higher points. However, the danger in concentrating too much on red indicators is that core points could be lost.

All practices will soon be able to run software programs to assess their overall current points

status and identify weak areas. They should then prioritise deficits in easy and hard areas. Summarising notes, 10-minute appointments, staffing levels, training and patient surveys will all form part of the strategy.

Over the next few week we will look at each quality point area in turn to define the degree of hardness of each indicator, weigh up cost benefits and offer tips on achieving high point scores.

Outline of quality framework categories

Category Number of Maximum

indicators points



Coronary heart disease 15 121

Stroke/TIAs 10 31

Hypertension 5 105

Diabetes 18 99

COPD 8 45

Epilepsy 4 16

Hypothyroidism 2 8

Cancer 2 12

Mental health 5 41

Asthma 7 72


Records and information 19 85

about patients

Information for patients 8 8

Education and training 9 29

Practice management 10 20

Medicines management 10 42

Patient experience 2 100

Additional services

(CHS, CS, Mat, Contra.) n/a 36

Linked payments

Holistic care 1 100

Quality practice organisational 1 30

Access target 1 50

Totals 137 1,050

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