Where quality meets outcomes

Professor Helen Lester, clinical lead in QOF development, talks to Summons about what goes into a clinical indicator 

THE QOF or Quality and Outcomes Framework has been much in the news lately with the recent launch of a 12-week consultation on proposed changes to the GMS contract – there now being the risk of a Government “imposition” of QOF changes should negotiations with the GPC in England fail. QOF is a system for the performance management and payment of general practitioners in which quality and outcomes are incentivised. The clinical indicators against which performance is measured are developed by a group of external contractors led by Helen Lester, professor of primary care at the University of Birmingham. She is also a practising GP.

Eight years down the line from the 2004 contract do you think that QOF has achieved its overarching goal? Is the UK a healthier nation?

Yes. I do think some of the improvements in health we’ve seen in the last few years in people with longterm conditions are associated with QOF. Part of the problem of answering that question with absolute conviction though is that back in 2003/4 when QOF was being dreamt up and negotiated I am not certain that anybody formally wrote down what the purpose of it was. And I think some of the problems that have come to light since then are related to the absence of that very simple task. If QOF was there as a GP pay rise then it achieved its goal in the short term but not in the long term because I think there have been elements of claw back – really since 2005 once the Government realised that GPs were going to receive a significant increase in their income. If the goal was to improve patient care then, yes, it did indeed achieve that but at quite a slow pace. I think we could have done it much more quickly had that been the stated clear primary aim.

What is your role in the QOF?

I lead the external contractor group and have done so since 2005. What we do is devise the clinical indicators – not the organisational ones. We are a collaboration of people working in the University of Birmingham and also the University of York. The cost effectiveness of the indicators is developed by YHEC [York Health Economics Consortium] and the clinical elements of the indicators – the wording, the feasibility, the face validity, the reliability of them, looking for unintended consequences and piloting them – that’s my group based in Birmingham. Since NICE took over the development of QOF in 2009 we have produced 75 indicators.

How is a typical indicator first conceived?

Well they all come out of NICE guidance. There is a board called the NICE Advisory Committee who discuss whether they think a particular clinical area is a good area to go to QOF or not. I’ll give you a real example. Rheumatoid arthritis (RA) is not currently in QOF. RA came to the committee about 18 months ago as a clinical area. They discussed it and decided that, yes, it was common enough. Yes, it was important enough in terms of morbidity. We, as indicator developers, said that we could see some indicators that could be developed in the area and in the end we were told to go away and do that.

We then worked with a group of senior clinicians who are experts in the area of RA, based in Keele. We asked – what are the key issues? And they said you need to think about things like cardiovascular morbidity because people with RA are much more prone to heart attacks. You need to think about fracture risk. You need to think about having annual reviews.

In the end we created five clinical indicators and put them through our 35 pilot GP practices for six months – and the results of the pilot were sent back to the Advisory Committee along with recommendations as to whether they should go forward or not. The Advisory Committee don’t have to take our recommendations but pretty much always do – I hope because they represent the views of frontline GPs – and these then go on to the NICE menu of short-listed indicators and get sent to the negotiators.

What makes a clinical area QOFable?

There are a whole range of different factors but it does have to be a condition that is both common and important. Coughs and colds are common but people on the whole don’t tend to die of them. Motor neurone disease is incredibly important but very rare. So that’s why coughs and colds and motor neurone disease are not in QOF. It also has to be something that any GP in the land is able to do. So if it relies on a service that is only available in three parts of England, then that’s not going to make a good indicator, although this is not an automatic bar to piloting or even inclusion in the NICE menu now. The condition also has to have a significant impact on the patient’s life. Above all, indicators have to be evidence-based. One of the reasons why I hang on in there with QOF is because it’s evidence-based medicine. The moment we start putting things in that are not evidence-based is the moment you need to start worrying about QOF.

Are indicators designed to have a finite life span?

No, but one might argue that indicators ought to be removed once they’ve run their course and patient level improvements have occurred. But removing indicators is a political negotiation. Some indicators, some process measures, were removed from QOF earlier this year. What the evidence base says is that indicators work very well for a couple of years. So you get an improvement in achievement and then that achievement plateaus. You can’t get an achievement much above 92 or 93 per cent. But traditionally the indicators have tended to stay in and not be removed.

Of course, if you take an indicator out that creates more workload for primary care. So it’s not always a terribly popular move to remove an indicator where everyone is achieving very good scores and then putting in a new indicator where there is fresh work associated. But if you want to improve patient care, that’s what you need to do. So your question was: do they have a finite life span? No they don’t but I personally think that they should probably stay in a couple of years and then be removed.

One criticism heard among GPs is that the QOF is a box-ticking exercise that focuses only on what’s easy to measure and ignores the “softer aspects” of what it takes to be a good GP. Is that fair?

A good indicator has to be valid and reliable. If you put in an indicator that is not tightly defined then that means there is huge room for interpretation and therefore also room for poorer care as well as improved care. So I would love to be developing psychosocial indicators because one of the joys and part of the art of being a GP is the less auditable ‘softer’ side of what we do. But if you want to improve blood pressure management, ultimately the indicator has to be whether blood pressure is below the target level. So I would argue that in QOF, we are not taking any of the art away but we are paying against the science.

What do you find most challenging about your role in the QOF?

The politics. You send your “children” out there, your indicators, and they get mixed in this political maelstrom of whatever the Government initiative of the day is and sometimes they come through the other side and sometimes they just get lost. I love the people that I work with. I love the actual process. I love working with the pilot practices. The only frustration is the politics at the end.

Interview by Jim Killgore, editor of Summons

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