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Context and Contents of Quality Outcomes Framework

What is the QOF?

The Quality and Outcomes Framework (QOF) is a system to remunerate general practices for providing good quality care to their patients, and to help fund work to further improve the quality of health care delivered. It is a fundamental part of the General Medical Services (GMS) Contract, introduced on 1st April 2004. The core philosophy underpinning the QOF is that incentives are the best method of resourcing work, driving up standards, and recognising practices’ achievements.
The QOF measures achievement against a range of evidence-based indicators, with points and payments awarded according to the level of achievement. It is a voluntary part of the new GMS Contract; general practices can aspire to achieve all, part or none of the points available in QOF.  The benefits of the information available through the introduction of the QOF include:
  • Enabling individual practices to identify/prioritise practice developments;
  • Enabling the Health and Social Care Board to consider practice developments, and identify areas of health inequalities at a local level;
  • Enabling the Department of Health, Social Services and Public Safety (DHSSPS) to plan health services.
Publication of detailed results for every general practice in the country is inevitable under the Freedom of Information Act 2000 but it is important that the data are not taken out of context. A lower quality achievement does not necessarily mean that patients are receiving poorer quality care. Taking part in the QOF is voluntary and there will be a whole variety of reasons why some practices may not achieve as high quality scores as others, many of them outside the direct control of the practice. It should be stressed that participation in the QOF is only one measure of the quality of clinical care provided to patients. This context should be taken into consideration when looking at the figures.


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Summary of QOF points and pounds available 2012/13

The QOF is not about performance management of general practice but about resourcing and rewarding good practice. This will benefit both patients and the wider Health Service. For example, there should be a reduction in avoidable hospital admissions due to improved chronic disease management. The QOF measures a general practice’s achievement against a scorecard of 148 evidence-based indicators, allowing a possible maximum score of 1000 points. The evidence-based indicators span four domains: clinical, organisational, patient experience and additional services.  The distribution of points is laid out in more detail in the following table.  Full details of each domain and points allocated can be found in the GMS Statement of Financial Entitlement.

QOF – points and payments available to GMS practices, 2012/13

1) Evidence Based Indicators Number of Indicators Total Points Available Pounds per point
Clinical Domain 96 669 variable1
Organisational Domain 42 254 £129.88
Patient Experience Domain 1 33 £129.88
Additional Services Domain 9 44 variable2
 
TOTAL3 148 1000
Footnotes:
  1. Within the Clinical Domain, the baseline £129.88 (2012/13) per point is adjusted up or down for each practice according to the prevalence of each clinical condition for that practice’s patients. See “Prevalence Data in the QOF” later in this publication for further information.

  2. Within the additional services domain, the baseline or £129.88 (2012/13) per point is adjusted up or down by the relative size of the practice’s target population compared to the Northern Ireland target population.

  3. All the payments in the four domains plus the additional payment points are added together to give the total payment for the practice.  This payment is then adjusted up or down by the practice's list size relative to the Northern Ireland average list size.

The four QOF domains cover the following areas:

  • Clinical Domain: 96 indicators in 22 areas (Asthma; Atrial Fibrillation; Cancer; Cardiovascular Disease - Primary Prevention; Chronic Kidney Disease; Chronic Obstructive Pulmonary Disease; Coronary Heart Disease; Dementia; Depression; Diabetes; Epilepsy; Heart Failure; Hypertension; Hypothyroidism; Learning Disabilities; Mental Health; Obesity; Palliative Care; Smoking; Stroke and Transient Ischaemic Attacks; Osteoporosis; and Peripheral Arterial Disease) worth up to a maximum of 669 points (66.9% of the total).

  • Organisational Domain: 42 indicators in 6 areas (Records and Information about Patients; Information for Patients; Education and Training; Clinical and Practice Management; Medicines Management; and Quality and Productivity) worth up to a maximum of 254 points (25.4% of the total).

  • Patient Experience Domain: 1 indicator on Length of consultations worth up to a maximum of 33 points (3.3% of the total).

  • Additional Services Domain: 9 indicators in 4 areas (Cervical Screening; Child Health Surveillance; Maternity Services and Contraceptive Services) worth up to a maximum of 44 points (4.4% of the total).

As of 1st April 2006, the quality practice payment points and the access target points were removed from the QOF.  The access target is now solely a directed enhanced service, details of which can be found under section 3 of the GMS Statement of Financial Entitlement.
As of 1st April 2008, the Holistic Care payment was been removed from QOF and the points reallocated to the new patient experience indicators
From April 2009, nine new indicators were added to the QOF; the points for the new indicators were reallocated from adjustments to the points of six existing indicators, and four indicators which were removed; the total QOF points available remained at 1,000 points.
From April 2011, key changes were the retirement of eight clinical indicators and four non-clinical indicators; the introduction of three new clinical indicators and 11 new organisational indicators for improving Quality and Productivity; and the rewording or replacement of a further 15 existing indicators with 21 new or amended indicators.
From April 2012, two new clinical areas were introduced– Osteoporosis (three new indicators) and Peripheral Arterial Disease (four new indicators). Five Quality & Productivity indicators were removed and replaced by three new indicators; two clinical indicators were retired, and two new indicators were added to existing clinical areas; and a further 13 existing indicators were revised and replaced with 14 new or amended indicators.

Source of QOF and Prevalence Data

The source of QOF tables published by the Department of Health, Social Services and Public Safety (DHSSPS) is the Payment Calculation and Analysis System (PCAS), a Northern Ireland IT system that supports the QOF payment process. PCAS was developed to provide practices with objective evidence of the quality of their patient care and to reward them financially for providing that care. The system ensures consistency in the calculation of quality achievement and prevalence. PCAS also gives general practices and the Health Board objective evidence and feedback on the quality of care delivered to patients. PCAS was developed by MSD Informatics, which is part of the Merck, Sharp and Dohme pharmaceutical company.

Practice List Sizes

The 2012/13 QOF tables published by the DHSSPS use practice list sizes supplied to PCAS from the National Health Applications and Infrastructure Services (NHAIS), the national general practice payments system, as at 1st January 2013.  A more familiar term maybe the “Exeter Payment System”. These are the figures used in PCAS for the list size adjustments in final QOF payment calculations.

How Practice Data gets into PCAS

A practice’s data enters the PCAS system in two ways:
  • The data to support the clinical quality indicators is extracted from individual practice GP systems using a software tool supplied by the relevant clinical software supplier, which ensures that this particular practice system produced the accredited QOF extract. The data is then extracted and transferred manually to the PCAS system.

  • Organisational, patient experience and additional service indicators (that is those indicators that require simply a yes/no response) are entered by the practice directly into a spreadsheet and submitted by practices to the PCAS system via the remote server.

Level of Detail

QOF information is collected at an aggregate level for each general practice. There are no patient-specific data within PCAS. For example, PCAS will capture practice-aggregated information on patients with coronary heart disease and practice-aggregated information on patients with diabetes, but it is not possible to identify or analyse patients with both of these diseases.




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Information for the User

What cannot be provided

The DHSSPS can only provide information that it holds in its QOF database, derived from the PCAS system. Any additional information about general practices, or activity of general practices that is not held in the PCAS system, is not available. For example, there is no information available about individual patients. PCAS was designed to collect information to support the calculation of practice QOF payments. It does not hold additional information around QOF, such as information on practice annual review visits by the Health and Social Care Board.

Secondary Use Issues

The published QOF tables for Northern Ireland provide healthcare organisations, analysts and researchers with a potentially rich source of information on the provision of general medical services. However, it is recognised that levels of QOF achievement will be related to a variety of local circumstances and should be interpreted in the context of these circumstances. Users of the published QOF tables should be particularly careful to undertake comparative analysis on this basis. The following points should be noted:
  • The ranking of practices on the basis of QOF points achieved, either overall or with respect to areas within the QOF, may be inappropriate. QOF points do not reflect practice workload issues, for example, around list sizes and disease prevalence – that is why payments include adjustments for both these factors.

  • Comparative analysis of practice, HSS Board or LCG level QOF achievement may also be inappropriate without taking account of the underlying social and demographic characteristics of the populations concerned. The delivery of services will be related to, for example, age/gender, socio-economic and deprivation characteristics not included in the QOF data collection process.

  • Users of the data should be aware that different types of practice may serve different communities. Comparative analysis should therefore take account of local circumstances such as numbers of students, homeless people, drug users and asylum seekers.

  • Analysis of co-morbidity (that is, patients with more than one disease) is not possible using most QOF data. There are no patient-specific data held within PCAS. For example, PCAS will capture practice-aggregated information on patients with coronary heart disease and practice-aggregated information on patients with diabetes, but it is not possible to identify or analyse patients with both of these diseases.

  • It is important to note that the information held within PCAS and therefore the source for these published tables, is dependent on diagnosis and recording within practices using the clinical information systems.


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Exception Reporting

Practices may on occasion exclude specific patients from data collected to calculate QOF achievement scores. For example, patients with specific diseases can be excluded from the denominators of individual QOF indicators if the practice is unable to deliver recommended treatments to those patients (the GMS Contract sets out valid exception criteria).  Exception reporting tables can be accessed from the QOF menu subsections of the left.
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Key Stages in the QOF Process

The following is a summary of the key stages in the QOF process. Further details can be found in the GMS Statement of Financial Entitlements.
The QOF reflects a voluntary cycle of continuous quality improvement in standards of patient care. This requires practices and the Health and Social Care Board to:
  • Plan – work out how many of the QOF points available it is realistic to aspire to, and ways to deliver care using the resources available.

  • Action – deliver high quality services and record achievement on practice systems

  • Assess – calculate QOF points and payments

  • Learn – reflect on how quality of care and points scored could be improved for the next year
Agreement of QOF Aspiration Levels: Before the start of each financial year general practices are asked to identify how many of the total 1,000 points available under QOF they think it is realistic for them to aspire to in the next financial year, given their local circumstances and resources. This aspiration level is agreed with the Health and Social Care Board.
Monthly Aspiration Payments to Practices: These payments provided in-year financial support against likely QOF achievements. The payments published on this website include both the aspiration payments and additional payments required once final achievement against the QOF was assessed.
Calculation and Sign-off of Achievement Points and Payments: The numerators and denominators are produced within the practice’s clinical system and the relevant software supplier’s tool ensures the accredited QOF clinical extract is produced. The practice enters the non-clinical data directly into a spreadsheet. These are submitted by practices to the PCAS system via the remote server.  Achievement points are automatically calculated within PCAS.  Practices and the Health and Social Care Board review what has been calculated, with the Health and Social Care Board required to confirm and sign-off all achievement payments before they are made. The data published within these web pages include achievements for all practices whose points and payments were signed off by 30th June each year.  Where practices have entered the formal disputes process to resolve issues regarding achievement points, tables are highlighted as provisional rather than identify these individual practices.


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Prevalence Data in the QOF

Overview

Data on the prevalence of specific diseases or conditions is an important element of the QOF and will be of particular interest to many parties. Prevalence is a measure of the burden of a disease in a population at a particular point in time (and is different to incidence, which is a measure of the number of newly diagnosed cases within a particular time period). Prevalence data are used within QOF to calculate points and payments within each of the clinical domain areas. Specifically:
  • Points can only be awarded to a practice for a given clinical domain area if the practice can produce a register of patients with that disease or condition, and

  • The number of pounds per point in each clinical domain area is adjusted up or down according to each practice’s prevalence for each disease or condition, relative to the estimated regional Northern Ireland prevalence for that disease or condition.
Note that some of the new clinical domains are not measuring prevalence of a disease or condition.  For example the depression 1 register counts the number of patients with diabetes and/or CHD for whom case finding for depression has taken place.  Also the smoking domain register counts the number of patients with specific conditions whose smoking status has been recorded; this therefore cannot be used to determine prevalence of smoking.
In general the new registers should be treated with caution in the first year of reporting as they are still being established and validated.

Reported Prevalence

The raw prevalence for each practice is calculated by dividing the number of patients on the relevant register by the number of patients the practice has on its total registered list. The prevalence data published here are shown as rates per 1,000 patients. For example:
Calculation of Practice Asthma Prevalence

A practice has 105 patients on its asthma register as at National Prevalence day.
The practice’s total list size at 1st January was 2,500.
The raw prevalence estimate (per 1,000 patients) = (105 / 2,500) x 1,000 = 42
For Northern Ireland reporting of PCAS information on these web pages, DHSSPS is reporting only raw (unadjusted) prevalence – that is, the number on a register on prevalence day of each year reported as a proportion of patients on a practice list as at 1 January of the same year.  Prevalence reports can be accessed on the QOF menu subsections.

Prevalence used in the Final Payment Calculations

Practice register counts used for final payment calculations in PCAS are based on National Prevalence Day (14 February of each year up to 2008/09, when Prevalence day was moved to 31st March to bring it in line with Achievement day). PCAS uses these counts to perform an adjustment to practices’ QOF payments, based on levels of prevalence. The “adjustment factor” was calculated centrally by Information and Analysis Directorate (IAD), DHSSPS and is based on an arithmetical formula that transforms the raw prevalence figure.

Use of Prevalence Data in Calculating Points and Payments

What follows is a summary on the use of prevalence data in QOF calculations.
The aim of the prevalence adjustments in each of the QOF clinical domain areas is to deliver a more equitable distribution of payments in the light of different workloads that practices face in achieving the same number of points. Practices with a high prevalence of a specific disease or condition will receive more pounds per point for that clinical domain area than practices with a low prevalence of the same disease or condition. However, the calculations are set such that even practices with very low prevalence of a given condition still receive a minimum payment for providing appropriate services for the disease or condition. This is because, even if there are only a small number of patients on the disease register, practices still have significant costs in identifying morbidity and establishing systems to support those patients effectively.
The basic pounds per point, £129.88 in 2012/13, in each clinical domain area is adjusted up or down according to each practice’s prevalence for each disease or condition, relative to the estimated Northern Ireland prevalence for that disease or condition. The amount by which the pounds per point is adjusted up or down is known as the Adjusted Practice Disease Factor (APDF).  For example, a practice with an APDF of 1.20 for asthma has a 20% higher adjusted prevalence than the Northern Ireland figure, and the adjusted pounds per point for asthma in 2012/13 = £129.88 x 1.20 = £155.86 per point.
A more detailed explanation of the method used to calculate APDFs is contained in Annex F of the GMS Statement of Financial Entitlements.

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