The QOF seems set to be a casualty of the commissioning revolution cutting a swathe through primary care.
NHS England has given the green light for CCGs across England to ditch the framework as they please and replace it with the agreement of local practices, without having to seek explicit permission.
And a Pulse investigation has revealed that CCGs have the hunger to do just that.
At least 12 CCGs are already discussing plans to replace the QOF with local incentive schemes, with one CCG aiming to implement it as soon as April.
The plans vary, but Pulse has learned that GPs in some areas could be given the option, if they wish, of funding for longer appointments for certain conditions and working with secondary and community providers towards shared outcomes, instead of following the QOF.
The GPC is understandably concerned about potentially losing one of the most prominent pillars of the national GP contract. But this concern is not necessarily shared by grassroots GPs, some of whom believe it will help cut bureaucracy and focus on local priorities.
The dismantling of the framework is just part of the wider drive towards CCGs co-commissioning primary care in England, which some are predicting could eventually lead to the end of the national GP contract.
A Pulse investigation of more than 150 plans from CCGs for co-commissioning of primary care – submitted last year – found 12 CCGs that said they were looking to replace the QOF with local schemes.
NHS Dudley CCG is looking to offer practices the chance to replace parts of the QOF and instead focus on raising standards in one particular patient group.
Its chief officer Paul Maubach says there are some areas of the QOF ‘we think are quite useful’, but the CCG has been reviewing the parts that are covered through other policies, either locally or nationally, such as smoking, arthritis, osteoporosis and sexual health.
What could replace the QOF?
The ideas that CCGs have on how to use QOF funding differently include incentivising:
• Longer appointments
• Quarterly reports
• Sharing patient records
• Focusing on one particular chronic disease
• Opening up practice books
Source: Pulse investigation
‘We think those areas can be more meaningfully replaced. We’re thinking of having a significant focus on one area. We haven’t agreed this yet but it could, for example, be hypertension.’
The CCG is currently considering how to merge primary care, secondary care and community care incentives so all bodies work towards the ‘same outcome objective’, Mr Maubach adds.
It is a similar story at NHS Aylesbury Vale CCG, which wants ‘significantly more care to be undertaken out of hospital’, according to chief officer Lou Patten.
‘In order to achieve this, we need to align all commissioning intentions and contracting incentives,’ says Ms Patten. ‘We are currently looking at specific projects, such as diabetes and our locality-led over-75s projects, to see what further improvements we could deliver if there was some alignment of GP incentives instead of the QOF.’
NHS West Hampshire CCG is also looking at merging incentives to focus on long-term conditions – and this could also include GPs offering longer appointments for certain conditions.
CCG chair Dr Sarah Schofield says: ‘What we might be interested in saying is, GPs need half-hour appointments with patients who have specific long-term conditions, and they would have to do that, say, three or four times a year.’
She adds that merging primary and secondary care incentives ‘is one of the ideas being talked about – if you want to pull care closer to communities and patients, it seems nonsense to have separate primary and secondary rewards systems’.
The introduction of local schemes would require the agreement of local practices to opt out of the national QOF and sign up to any new incentive scheme.
Pulse has found that some LMCs have not only lent their support to the idea of replacing the QOF, they have been suggesting ideas themselves. Dr Ivan Camphor, secretary of mid-Mersey LMC and a GP on the Wirral – where the local CCG is looking to drop the QOF – says: ‘There is no doubt in my mind that the QOF, or a large proportion of it, will be replaced. I think it is going to help practices because the QOF can be quite rigid, whereas if you have local flexibility you can address needs in a more comprehensive and holistic manner.’
Dr Camphor has advised NHS St Helens CCG on potential QOF alternatives, as the LMC representative, and says the move to commission primary care ‘has been received in a positive way’. A local QOF ‘goes to the core of it’, he adds, ‘giving GP practices and patients a say in determining local health needs’.
Dr Nigel Watson, chair of Wessex LMCs, which covers NHS West Hampshire CCG, and former chair of the GPC commissioning subcommittee, supports in principle the idea of introducing local flexibility to the QOF.
He says he has not yet been presented with the CCG’s plans, but adds: ‘I don’t think it will simply be a case of CCGs replacing the QOF with something else. There will be a national negotiated contract with local flexibility. Most GPs will welcome it if it’s better, but it remains to be seen what we actually get.
‘I want local flexibility if it benefits me, not if it doesn’t. We need to make sure people don’t put in new measures that are just as bureaucratic as the old ones.’
More CCGs could now follow, after guidance released by NHS England in November gave all CCGs the green light to replace the QOF if they take on full primary care commissioning responsibilities from April. It says: ‘There will be no formal approvals process for a CCG which wishes to develop a local QOF scheme or DES.’
It does stipulate that any new scheme must be ‘subject to consultation’ with the LMC, and must ‘be able to demonstrate improved outcomes, reduced inequalities and value for money’.
Since the guidance was published, Pulse has asked more than 50 CCGs about their intentions for co-commissioning, and found more than two-thirds are interested in taking the highest level (level 1) of responsibility for co-commissioning – which would allow them to ditch the QOF without approval. A further 28% want to take on a ‘level 2’ joint commissioning role with local area teams, which also allows the abolition of the QOF in favour of a local scheme, with the consent of the local area team. A third level allows CCGs just to influence their local area team.
CCG view: ‘The outcomes we want are hard to achieve through the QOF’
Everything is currently in the development phase but we are thinking about replacing parts of QOF. If I was going to give an all-encompassing term, it is the long-term conditions where we would certainly make a start.
Our outcomes for diabetes for patients are not brilliant compared with other areas of the country but we are very high QOF achievers.
That means diabetes may be a good place to consider an outcome-based measure looking at how patients are benefiting, rather than just counting activities.
This is the case for several of our long-term conditions. Respiratory medicine is another area where we have a good strategy and lots going on but, yet again, delivering for patients doesn’t necessarily seem to be achieved through the QOF. Other areas are cardiovascular disease, stroke and hypertension.
A lot of the longer-term outcomes that we may hope for, such as a reduction in amputation rates from diabetes, are difficult to achieve through the QOF approach.
At this stage, we have not got definite plans for [what sort of outcomes would prompt GP payment] and I would probably suggest we need to do a lot more work on that.
But we are working very closely with our public health colleagues to try to develop some in-year measures that would be appropriate.
Dr Sarah Schofield is chair of West Hampshire CCG and a GP in North Baddesley
NHS England is calling on CCGs to look at the example of NHS Somerset CCG. In conjunction with the LMC and the local area team, most practices in the area opted out of the QOF in favour of a new local incentive scheme last June. Practices were given the option of stopping QOF reporting in favour of other duties, such as sharing patient records and a special notes system with other care providers locally, and opening up practice books to the CCG and area team to ensure they are financially sustainable over the next five years.
Dr Amanda Doyle, co-chair of NHS Clinical Commissioners and NHS England’s adviser on the Next steps towards primary care co-commissioning guidance document, says CCGs ‘wouldn’t have time to put anything in place for the 2015/16 contract year’.
She adds: ‘That will allows CCGs and NHS England to evaluate the Somerset pilot and roll out any learning from that.’
However, that isn’t entirely in line with the thinking of CCG leaders.
Mr Maubach says NHS Dudley CCG is hoping to start the ‘first stages from 1 April’, while Dr Schofield says: ‘I would be reluctant to just be sitting and waiting for someone else to produce outcomes.’
The speed of these moves reflects the chequered history of the QOF as a whole. Introduced in 2004, it was an attempt to drive up clinical standards in a consistent manner across the UK.
But in the past few years, the QOF has lost support as NICE took it over and began introducing more controversial indicators, and after the introduction of the ‘quality and productivity domain’ distorted its evidence-based approach.
As a result, the GPC and the Government last year agreed to cut the size of the QOF radically, with the 1,000 points available in 2012 being almost halved to just 559.
A Pulse survey of 413 GPs in July last year showed almost half (46%) would back a switch to a local alternative to the QOF. Just 17% said they would not, with the remainder undecided.
But GP leaders are not willing to give up the QOF completely. GPC deputy chair Dr Richard Vautrey gives a stark warning: ‘GPs should not be fooled by the superficial attraction of moving away from the QOF.
‘The reality is, this will increase workload, not reduce it, as data linked to each QOF indicator would continue to be extracted from GPs’ IT system and they’d still be performance managed against it, while at the same time expected to do even more work, paid for by the small amount of money that was funding the QOF.’
However, the GPC acknowledges it does not have the power to prevent CCGs initiating their own incentives schemes. As such, the future of the national QOF lies in GPs’ hands.
Should my practice go local?
Dr Nigel Watson gives three questions to ask before deciding on opting out of the national QOF
1. Will a local QOF benefit patients more than the national QOF?
For example, regarding diabetes, where appropriate it is important to set targets for HbA1c, blood pressure and cholesterol, but they will depend on an individual’s age and the general state of health. So would it be better to have an indicator that provided patients with a personalised care plan with agreed targets, or ensuring 90-year-olds meet a cholesterol target that is more relevant to a 50-year-old? That’s not particularly valuable in the current QOF and I’m not convinced you need to tick a box for this.
2. Will it reduce bureaucracy?
The problem with some local QOFs seems to be that practices are expected to continue to meet all the targets in the QOF and the CQC also uses this in its so-called ‘intelligent monitoring’, yet a local QOF would mean there is a different set of targets to achieve.
3. Do you want stability?
I wonder if CCGs have the time or experience needed to develop a good set of indicators. CCGs can’t unilaterally get rid of the QOF; they have to get practices to agree to opt out and adopt a viable alternative. Some GPs may prefer to stick with the QOF they know – they may want stability.
Dr Nigel Watson is chief executive of Wessex LMCs and former chair of the GPC commissioning subcommittee.