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GPs go forth

What will the QOF overhaul mean for GPs?

The QOF is to be rewritten, localised and its payment system overhauled - Pulse looks at the complex changes

By Lilian Anekwe

The QOF is to be rewritten, localised and its payment system overhauled - Pulse looks at the complex changes

The QOF has been accused of not keeping up with the times, but in a climate of global turmoil and upheaval, it is bang on trend.

With storm clouds not so much gathering as raining down on the nation's economy the Government has turned again to the GP contract – famously derided as too generous – and is desperately trying to wring as much value for money out of it as it can.

And that means wholesale changes for the QOF, with a pivotal role for NICE in setting new indicators, tougher outcome targets, local flexibility and a new formula for calculating payments. So how will all this affect GPs on the ground?

Some of the changes are more definite than others, first among them the end to the controversial square root formula, which the GPC and NHS Employers have agreed will be scrapped, after apparently being left with little option by ministers.

‘We could have got rid of it more gradually, over 10 or so years, but there's no way the Government would have accepted that. It wanted it gone as quickly as practically possible' says Dr Laurence Buckman, GPC chair.

‘We've tried to make it painless but it can never really be. I've got enormous sympathy for those practices who will lose out but I don't have any clever answers,' he says.

Someone who has tried to provide some answers is Swindon GP Dr Gavin Jamie. His calculations show that when the square rooting component of the formula is removed certain types of practices – university practices and those with only a few patients on QOF disease registers – will lose the equivalent of 234 points, or £23,000.

‘University practices will be hit hard, to the point of almost making QOF irrelevant to them. Over time their QOF work will become almost negligible in terms of income,' he says.

The GPC insists the shift to a formula that reflects true prevalence will be cost neutral. But Dr Jamie's modelling suggests this may not be the case.

Practices in London PCTs, including Lambeth and Westminster, will lose the equivalent of over 100 points per practice, while County Durham PCT will have to find another £1.5m every year to support income lost by practices through the change.

‘It's not something immediately obvious to practices but most will gain or lose around 50 points equivalent,' Dr Jamie says.

‘Nationally the changes probably are cost neutral, but certainly not at PCT level. It's going to be interesting to see what happens, especially in places with so many other health needs. It's probably going to be left up to PCTs to decide whether to support these practices.'

Trusts have yet to show their hand and reveal whether they will support practices or risk letting them go to the wall. And the theme of PCT power also features in the DH's QOF consultation, which is considering a local QOF that would allow PCTs flexibility to choose indicators suiting the needs of their populations from a national menu.

Ministers feel there is ‘significant potential for increasing patient benefit by devolving responsibility for choosing QOF indicators', either for PCTs to choose for all of their practices or to be varied from practice to practice.

But Dr Buckman is ‘more convinced than ever' that the local QOF proposals couldn't work. ‘A local QOF is not the correct mechanism to deal with health inequalities. That needs doing and is an important job for society. But the QOF is not some fund PCTs can raid. This is my pay – don't tinker with it.'

The BMA's other concern is that allowing trusts to pick their own indicators may actually create health inequalities. But if managed properly, Dr David Jenner, contract lead for the NHS Alliance and a GP in Cullompton, Devon, thinks it can work.

‘I understand where the BMA is coming from, because it is a national trade body that wants to retain national negotiating rights. It has seen many local schemes in the past that have been of dubious quality and is right to be wary.

‘But if a local QOF were nationally informed by consultation with the public and the profession a lot of the arguments would fall away. I don't think it has to be one national template for everything.'

Speculation is rife around how much of the QOF might remain national or could be devolved to PCTs. Dr Jenner and Dr David Colin-Thomé, the DH's primary care tsar, have both gone on record saying only 5-10% should be local, while Adrian Jacobs, the joint chair of the NHS Employers' negotiating team, thinks as much as a third could be locally decided.

Professor Helen Lester, professor of primary care at the University of Manchester and joint chair of the QOF expert review panel, backs the plans for a local framework. She suggests indicators for screening people for substance misuse – currently offered as a direct enhanced service – ‘would be perfect for a local QOF'.

‘There's a cost to substance misuse, but it's not a significant problem everywhere. That sort of indicator would lend itself nicely to being included only where PCTs have a need for it.'

Professor Lester is also supportive of many of NICE's plans for the QOF, which she says are long overdue, and is not as resistant as some GPs to proposal that indicators should be removed once they become part of routine care.

‘You could argue GPs don't stop doing work once it's no longer incentivised, and in that sense workload could get bigger and bigger. It's a genuine concern. But equally you can't have everything in the QOF at any one time. Ideally it should be like a lighthouse, with a light shining on only one sector at a time, in regular rotation.'

Professor Lester is working on a study, run jointly by the US Kaiser Permanente research group, to assess whether the quality of GP care drops when indicators are not incentivised for two to three years and then reintroduced.

‘It'll be interesting. If the results show removing incentives has no impact on quality that's an argument in favour of retiring or cycling indicators. But if removing incentives is shown to be detrimental that's definitely something that should inform future health policy.'

Despite her expertise, Professor Lester's role and that of the QOF expert review panel will be swept aside in the new NICE-led system.

The prospect of collusion with NICE fills some GPs with dread, with fears the public image of the profession may be damaged by the association.

One GP told Pulse's website: ‘NICE seems to have a very bad public image. My worry is the QOF – and what we do as GPs – will become tarred with the same brush, with patients thinking all we think about is the bottom line cost of their treatment.'

This fear may not be entirely unfounded. The primary care consideration panel, which the DH told Pulse will include health economists as well as GPs, patients and carers, commissioners and nurses, will retire old indicators and reject proposed indicators if they do not meet NICE's £30,000 per quality-adjusted life year threshold.

‘It's easy to see the political drivers behind some of the recommendations,' Professor Lester says. ‘So much of this comes down to money – I think if the QOF represented a smaller proportion of GP pay the pressure to justify every penny would lessen.'

Analyses by DH-funded health economists suggest several indicators that are considered fundamental elements of clinical practice are not cost-effective when assessed in black and white terms.

Diabetic retinopathy screening costs more money than it saves - £21 more for every patient treated, to be precise. Crucially, however, this cost analyses does not taken into account the health costs saved longer-term by preventing blindness.

The dilemma of where to draw the line of cost-effectiveness is the kind NICE regularly faces but that GPs will be keen to avoid. A QOF that places heavy emphasis on value for money may not be able to capture the more nebulous, patient-level benefits of general practice.

‘At the moment I deliver effective health care', says Dr Buckman. ‘Whether or not that's cost-effective I don't know, but if I have to be mindful of cost then that might affect my clinical decisions.'

Value for money used to be a managerial buzzword or the language of political controversy, but it is increasingly becoming part of the daily reality for GPs.

Your guide to the QOF changes

Square root formula

Q: What's changing?
A: The formula paid for QOF work according to the square root of the ratio between practice and national average prevalence. From April 2009, the square rooting component will be removed. In April 2010 the second part of the formula, which capped or uprated QOF payments for practices with very high or low prevalence – will also be removed.

Q: Who will be affected?
A: The scrapping of the formula will benefit practices with a high prevalence of chronic diseases, which typically serve very deprived or elderly populations, and were previously seriously underpaid per patient treated.

Q: What will the effects be?
A: The BMA estimates for 90% of practices the changes will be minor. There will be a 50:50 split between winners and losers, with the average practice standing to gain or lose about £10,000. But 5% of practices with very high prevalence will get rises of up to £70,000. At the other end of the scale some practices will lose up to £100,000 a year in funding.

DH consultation

Q: What has the DH proposed?
A: The Department of Health has published a consultation document in which it sets out how the QOF should be managed and decided on in future.

Q: Why is it doing this?
A: Lord Darzi, in his Next Stage Review of the NHS, recommended NICE should take over the process for managing the QOF. This is designed to make the process more transparent and the QOF more cost-effective.

Q: How will things differ from the current system?
A: NICE is set to review 20-30 clinical indicators a year, with the intention of removing around 10 a year – where they are not cost-effective or embedded in practice. A new set of 10 indicators will be piloted and introduced, subject to negotiations between the GPC and NHS Employers.

Q: What else might happen?
A: NICE plans more outcomes-based measures, such as those for reducing blood pressure and cholesterol, and fewer points for processes such as making records or taking measurements. It also wants more public health indicators. NICE may also PCTs flexibility to choose some indicators from a national menu.

What will the QOF overhaul mean for GPs?

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