New QOF targets announced last month reward GPs for their commissioning roles for the first time. Alisdair Stirling gives a brief overview
What are the new QOF targets?
The indicators are worth a total of £12,500 to the average practice and consist of the following points.
• Prescribing – five indicators worth 28 points.
• Outpatient referrals – three indicators worth 21 points.
• Emergency admissions – three indicators worth 47.5 points.
• Total points – 96.5.
The prescribing indicators require practices to produce draft prescribing plans and awards points for the percentage of prescriptions that comply. For outpatients and emergency admissions, points reward internal and external peer review of outpatient referral data and emergency admissions – then there are further points for following three agreed care pathways.
What’s the background?
Prescribing, referrals and emergency admissions are three areas of significant cost where expenditure decisions are in the hands of GPs, so it makes economic sense for the Government to incentivise GPs to make savings. They are also a way of connecting with GPs and practices that have, until now, chosen to remain outside the commissioning agenda. They obviously overlap with the Department of Health’s Quality, Innovation, Productivity and Prevention (QIPP) programme – and many consortia have already embarked on schemes in these areas as part of the QIPP agenda agreed with PCTs.
Dr Michael Dixon, chair of the NHS Alliance and a GP in Cullompton, Devon, acknowledges the overlap, but believes the two initiatives are complementary: ‘They’re different but heading in the same direction. All front-line GPs know what the QOF is – only a few know what QIPP is.’
Dr Dixon believes the new indicators are an invitation to see quality in general practice as ‘not only what we do as providers, but also what we offer patients as prescribers and referrers’.
‘They define quality as not only what we offer an individual patient, but the whole patient population in terms of services available and whether there will be sufficient resources to go round – review of prescribing and referrals inevitably impacting on the latter,’ he says. ‘In short, commissioning is now what we do as GPs and something to be rewarded.’
When do they start?
Straight away. The first deadline – for conducting the prescribing internal review and agreeing three draft plans with the PCO – is at the end of next month.
What does this mean?
Individual practices will be forced to engage with one another and with commissioning locally. On the face of it, the new indicators could make life much easier for consortia – making it unnecessary to introduce their own schemes in these three crucial spending areas. Consortia or PCTs will be responsible for drawing up care pathways in each area, but achievement will be awarded on the basis that practices have engaged in the development and delivery of care along the agreed pathways.
How can consortia align what practices are doing with their own commissioning strategies?
The requirement for external peer review will help for all the indicators. There needs to be a minimum of six practices in the process. Practices in commissioning consortia have a history of working together and many have already been aligning areas.
Kym Lowder, pharmaceutical adviser to Primary Care Commissioning, believes the QOF could get practices to work together on prescribing: ‘While some practices might want to do their own thing, there may be pressure from their peers to work with areas that are most beneficial. It should lead to more ownership of prescribing changes, with greater involvement of practices rather than the singular PCT.’
Some GPs in consortia have already started working on this area in earnest and agreeing pathways with PCTs. For GPs in areas that already have a referral gateway, meaning it is not possible for them to change care pathways, they will still be able to claim points if they document the situation with NHS Employers.
Andy Lee, commissioning and NHS partnerships director at WG Consultancy, has been working with three GP consortia, implementing a similar system of internal review, peer review and referral pathways. He views the changes as potentially unfairly rewarding GPs: ‘Paying GPs for referral management is a game-changer. Until now QOF was about incentivising GPs as providers. But these new targets mean GPs are going to be paid for something they would have done anyway as commissioners. Consortia should discuss with practices the future funding of referral management schemes, given the QOF income they can now generate.’
This is another area where pioneering GPs have already been designing their own pathways. Dr Tony Brzezicki, a GP in Croydon, Surrey, and founding chair of the Commissioning 4 Croydon consortium, has already agreed a plan to have the ‘meet and greet’ in casualty done by primary care staff as part of the QIPP agenda. These staff will send anyone who doesn’t need to stay in hospital back to see their GP. Dr Brzezicki says: ‘The QOF targets will support our aims, but they’re really a distraction. I assume many practices will not bother with them.’
NAPC chair Dr Johnny Marshall welcomes how the QOF allows GP consortia to help practices. But he hopes the targets do not create the impression that all that needs to be done is achieve maximum points.
‘QOF parameters must not become fixed as this will prevent further innovation. Forward-thinking consortia have already carried out this work and are moving beyond it,’ he says.
Alisdair Stirling is a freelance journalist
What the new QOF targets mean for commissioning