CASE 14 for the National Health Continuing Improvement Service Quality and Outcomes Framework Curtis P. McLaughlin INTRODUCTION In April 2004, the United Kingdom's National Health Service (NHS) launched a nationwide pay-for-performance (P4P) effort for General Practitioners (GPs) called Quality and Outcomes Framework (QOF). This was a component of the five-year contract negotiated between the NHS Employers (acting on behalf of the Department of Health (DOH) and the General Practitioners Committee (GPC) of the British Medical Association. Payment was based on a set of indicators for the QOF devel- oped by a consortium of academic healthcare and information technol- ogy experts coordinated by the National Primary Care Research and Development Centre (NPCRDC), a joint effort of the universities of York and Manchester based at the University of Manchester. The negotiations and were published on the Centre's website after the negoti- NPCRDC recommendations remained confidential during contract ations. By 2009, the Framework had cost the NHS at least £1.8 billion. s such a large portion of the NHS budget that both the Govern- ment and Parliament were concerned about how to maintain and This was 259 CASE 14 CONTINUING 260 FOR THE QOF the lack of transparency in the process developing and selecting those improve its effectiveness going forward. They were also concerned about The va NHS coj indicators recorded che amou THE INDICATORS assessors by patien annually rice. The The 2004 contract called for indicators in four domains: clinical, organi- child-health surveillance, and contraceptive and maternity services). zational, patient experience, and additional services (cervical screening, The dinical indicators were of two types: 0-1 indicating the presence or absence of something such as a diabetes patient registry or linear across an interval allocating the allowed points between a minimum acceptable to improv worth 30 veys requ The havi 1. Scotland and NHS England and Wales in cooperation with NICE. A GP all if it was lacking. If the practice recorded retinal screening of more than 2. 3. I there were 16 indicators for diabetes mellitus care set value and a maximum compensated voreshold . For example, in 2005 by NHS Qulio received six points if he or she had the appropriate registry or nothing af 40% of its diabetes patients in the last 18 months, it could receive up to 5 points depending on where its percentage was in the 40% to 90% range. Clinical indicators could be for screening, treatment, and/or control. Other diabetic screening indicators included Body Mass Index and cho- lesterol levels recorded and screening for kidney problems. Treatment indicators included percentage of diabetic patients receiving influenza vaccine and percentage with micro-albuminuria or proteinuria receiving appropriate ACE inhibitors or A2 antagonists. The biggest potential pay- ments were for control variables including percentage of diabetics with Hb41c controlled at the 10 or less and 7 or less levels, blood pressure a 145/85 or less, and cholesterol at 5 mmol/l or less. 4. F V NHS Pri The Depa QOF in it ments as fo In the case of indicator DM18 the GP would receive 0 points if les than or equal to 40% of the relevant patients had been immunized, with the three available points spread over the range 40% to 85%. Values 98.5% of che possible points; however, the actual coverage was 90.2% higher than 85% still earned 3 points. For DM18, the practices received after an exception rate of 14.3%, the highest for any of the diabetes indi cators, presumably because many patients declined the immunization (Health and Social Care Information Centre, 2009). 1. Indi evid 2. The to th of ра NDICATORS 261 ned about cing those The values for most of the clinical variables were determined by the recorded in that system, such as the presence or absence of a registry or NHS computerized patient record system. Variables that were not the amount of time scheduled per visit, were determined annually by assessors who would visit each site. Some variables were also determined annually to 25 patients for each 1000 patients registered with the by patient surveys. Practices were required to administer post-visit surveys e practices were incentivized to act on these results and take steps to improve their performance. For example, achievement of the third level worth 30 points on Patient Experience Indicator 6 that related to the sur- 1, 1. Organi- tice. The prac- creening ces). presence veys required that: car across cceptable in 2007 Quality E. A GP othing at ore than · The practice will have undertaken a patient survey each year and, having reflected on the results, will produce an action plan that: 1. Sets priorities for the next 2 years. 2. Describes how the practice will report the findings to patients (for example, posters in the practice, a meeting with a patient practice group, or a Primary Care Organization approved patient representative). 3. Describes the plans for achieving the priorities, including indi- cating lead persons in the practice. ve up to to 90% control und cho of patients eatment nfluenza receiving tial pay 4. Considers the case for collecting additional information on patient experience, for example, through surveys with specific illnesses, or consultation with a patient group. ics with (NHS, 2008, p. 142) essure ar ts if less ed, with Values NHS Principles Concerning the QOF The Department of Health had specified its principles concerning the DOF in its contract with the GPs called Statement of Financial Entitle- Ments as follows: received 5 90.2% evidence. 1. Indicators should, where possible be based on the best available to the minimum number compatible with an accurate assessment 2. The number of indicators in each clinical condition should be kept tes indi- nization of patient care. the bar are very important to continued success. the apparent fairness and rationality of the process for continually raising ASSIGNMENT QUESTIONS 1. What do you consider to be the key issues for quality improvement in the NHS quality-improvement program as it goes forward? 2. What do you consider to be the strengths and weaknesses of the effort to improve the development of QOF indicators over the next couple of years? 3. The program appears to be using QALY metrics to justify the choices of future quality and outcome indictors. What are the strengths and weaknesses of such an approach to valuing quality? 4. Some researchers have expressed doubts about the improvement effectiveness of indicators in the high 90% range. What is your evaluation of this concern and what alternatives do you recommend? 5. Most U.S. P4P efforts do not allow for exclusion of a significant numbers of patients. What are the pros and cons of this and the one used by NHS? 6. NHS is a single payer system. How does this affect its design of the QOF system and its efforts to implement it? How do the much more complex U.S. payment systems affect its utilization of P4! systems? approach tems for evaluation. What are the strengths and weaknesses of such 7. The NHS QOF effort is obviously full of very specific point sys- quantification of decision rules in a health care environment? Implementing Continuous Quality Improvement in Health Care A Global Casebook Curtis P. McLaughlin Julie K. Johnson William A. Sollecito
Purchase answer to see full attachment