Page last updated: 29-SEP-2009

QOF

ONS kitemarkStatistical Publication Notice

29 September 2009

Quality & Outcomes Framework (QOF) of the new General Medical Services contract. Achievement, exception reporting and detailed prevalence data 2008/09 .

INTRODUCTION

The Quality & Outcomes Framework (QOF) is part of the new General Medical Services (GMS) contract.  Published here are Scotland's 2008/09 QOF data at individual general practice level as well as at Scotland, NHS Board and Community Health Partnership level.
 
The QOF measures a general practice's achievement against a set of evidence-based indicators, with payments made to practices on the basis of their achievements.  The QOF indicators are grouped into four 'domains': clinical, organisational, patient experience and additional services.  The clinical domain includes indicators around specific diseases or health conditions and accounts for the biggest part of the QOF in terms of points and payments available to practices. 
 
The data presented include points achieved by each participating practice, for individual indicators and indicator groups, as well as crude prevalence rates for selected health conditions, drawn from QOF registers.  The total QOF payment per GMS practice is also shown.  For practices with contract types other than a standard GMS one, the payment value is in some instances indicative, showing  the amount that they would be paid for their QOF achievements if they were a GMS practice.  The release also includes information on exception reporting in 2008/09.  Exception reporting allows practices to pursue the quality improvement agenda and not be penalised where, for example, patients do not attend for review, or where a medication cannot be prescribed due to a contraindication or side-effect.  Exception reporting is a specialist area of the QOF and separate explanations of this are given on a page specifically covering this area.

KEY POINTS

Across all practices with a new General Medical Services (GMS) contract in Scotland the average QOF points achieved, out of a maximum of 1000 available, has fallen slightly from 982.2 (98.2%) in 2007/08 to 972.0 (97.2%) in 2008/09.  This difference is mainly attributable to relatively low achievement in 2008/09 against the two new patient experience indicators, PE07 and PE08.
 
Total funding associated with the QOF in 2008/09 was approximately £128 million, down from roughly £131 million in 2007/08.  QOF payments are part of a total of around £705 million invested annually in Primary Medical Services across Scotland.
 
Amongst individual health conditions included in the QOF, the biggest improvement in achievement for 2008/09 compared with 2007/08 was observed for the mental health indicator group.  On average, practices with GMS contracts achieved 95.9% of the 39 points available for mental health indicators, compared with 94.7% in 2007/08.

INTERPRETATION

1. Achievement of full points may not be possible or desirable for some practices.
 
Participation in the QOF is voluntary; practices may aspire to achieve all, some, or none of the points available.  Additionally, whilst most Scottish practices with new GMS contracts have participated fully in the QOF, it is important to note that for some of them it may be impossible to achieve all of the points available in the framework.  For example, some of the clinical indicators relate to very specific subgroups of patients, and if the practice does not have any patients in that particular subgroup, they cannot score any points against the relevant indicator(s).
 
Approximately 13% of practices in Scotland have contract types other than GMS.  These practices may include quality and outcomes as part of their locally negotiated agreements, and in many cases, they opt to use part or all of the new GMS QOF as a measurement tool.  However, it is possible to tailor the quality and outcomes requirements of these 'Section 17C' or '2C' practice agreements in accordance with local circumstances' such as the needs of a particular group of patients.  Such practices might use quality measures that, although rigorous and appropriate, are not identical to those used in the GMS QOF.  Therefore, although 17C/2C practices may record full QOF data if they wish, they may deliberately use only part of the QOF, or may not use it at all.

2.  Changes to the QOF for 2008/09
 
  • There are some differences between the QOF in 2008/09 and the QOF in 2007/08.  This means that total QOF points and payments as well as some of the finer details for 2008/09 are not directly comparable with those for 2007/08. The main changes and points to note are:
  • Two new indicators in the Patient Experience domain were introduced for 2008/09.  These indicators, PE07 and PE08, were designed to reward practices for provision of appointments within two working days, and more than two days in advance, respectively.  The data for these indicators were collected through a national GP Patient Access Survey and are worth a combined 58.5 points.
  • There have been slight changes to individual indicators in the following clinical groups; Chronic Obstructive Pulmonary Disease (COPD), Smoking, Chronic Kidney Disease, Stroke and Atrial Fibrillation.  In all except COPD, whilst the indicators have changed, the points available to each practice remain the same.  However, for COPD there were 5 fewer points available per practice for 2008/09.  These changes should be taken into account when comparisons of achievement for these indicator groups are made with previous years.  There have however been no changes to the disease register for these groups, so prevalence comparisons can still be made.
  • The definitions of the disease registers for Palliative Care and Conditions Assessed for Smoking have changed.  In the case of Palliative Care the definition has been changed so that all patients, irrespective of age, are included (when it was first introduced for 2006/07 it was restricted to counting patients aged 18 years and over).  For Conditions Assessed for Smoking two extra conditions, Mental Health and Chronic Kidney Disease, have been added to the register.  Because of these changes it is not appropriate to make direct comparisons of these QOF-reported 'prevalence' rates for 2008/09 with those for previous years.

3. Prevalence rates derived from QOF registers need care in their use and interpretation. 

Prevalence is a measure of the burden of a disease or health condition in a defined population at a particular point in time (and is different to incidence, which is a measure of the number of newly diagnosed cases in a defined population within a particular time period).  Data on the prevalence of specific diseases or health conditions are an important element of the QOF and are of interest to many people.

Prevalence data within the QOF are collected in the form of practice 'registers'.  A QOF register may count patients with one specific disease or condition, or it may include multiple conditions.  There may also be other criteria for inclusion on a QOF register, such as age or time of diagnosis. 

QOF prevalence data should be used and interpreted with caution.  The main points to note are as follows:
 
  • QOF prevalence rates are 'raw' or 'crude' rates - which means that they are not adjusted to account for differences between practice populations in their age or gender profiles, or other factors that influence the prevalence of health conditions.  A QOF prevalence rate is simply the total number of patients on the register, expressed as a proportion or percentage of the total number of patients registered with the practice (the practice list size) at one point in time.  This means, for example, that an apparently higher prevalence of age-related conditions such as cancer or stroke in a particular practice might simply be due to it having an older patient age profile.
  • Some QOF registers are restricted to include only persons over a specific age.   However, the QOF prevalence rates use as their denominator the total (all ages) number of patients registered to the practice at one point in time.  Diabetes registers are based on patients aged 17 and over; epilepsy, chronic kidney disease and learning disabilities registers are based on patients aged 18 and over; and obesity registers are based on patients aged 16 and over.  This means that for these conditions the QOF-reported prevalence will appear lower than would be the case if the age restriction was also applied to the population denominator.
  • Prevalence figures based on QOF registers may also differ from prevalence figures from other sources because of coding or definitional issues.  For example, to be on the QOF diabetes register, patients need to be aged 17 or over and the type of diabetes (type 1 or type 2) must be specified by the practice.  If the type is not specified the patient will not be counted in the register.  Information on diabetes as reported elsewhere may not be subject to these restrictions.
Year-on-year changes in the size of QOF registers are difficult to interpret for various reasons including:- changes in epidemiological factors (such as an ageing population); improvements in case finding by practices; changes over time in the definition of the registers.  These points are addressed in more detail within our page on QOF Prevalence Rates for Scotland.

DETAILED FINDINGS

Achievement

As for 2007/08, achievement against the 2008/09 QOF was very high overall.  Any comparisons made between the latest and previous years should acknowledge that there have been changes to the QOF for 2008/09.

Across all participating Scottish practices with new GMS contracts, the mean number of points achieved in 2008/09 was 972.0, out of a maximum 1000 points available.  This is down slightly from a mean of 982.2 points in 2007/08.  This difference is mainly attributable to relatively low achievement in the two new patient experience indicators introduced in 2008/09, PE07 and PE08, which between them have an average achievement of 43.3 points out of 58.5 (74.0%).  In particular, achievement against the PE08 indicator was much lower on the whole than for other QOF indicators.  PE08 measures, for a sample of patients in each practice, 'The percentage of patients who, in the appropriate national survey, indicate that they were able to book an appointment with a GP more than 2 days ahead'.  Practices fared relatively better for PE07, which indicates the percentage of surveyed patients who said they could get an appointment with their practice within 48 hours of requesting one. 

The information shown for PE07 and PE08 is pending appeal by some practices across Scotland.  This means that there may subsequently be changes to the points and/or payments awarded to practices for these indicators for the 2008/09 QOF year, which in turn would impact on total achievement and/or payments.  If any amendments are made, further information about their nature will be published on ISD's QOF web pages (www.isdscotland.org/qof).

More information on the national GP Patient Access Survey, upon which the PE07 and PE08 results are based, is published at http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/GPAccessSurveyResults

Achievement in each of the clinical indicator groups was generally very high and in most cases  at least slightly higher than observed in 2007/08.

Across all practices with new GMS contracts, the percentage of available points achieved was highest for the hypothyroidism indicator group, at 99.9% (with a current maximum 7 points per practice).  This condition, a failure of the thyroid gland to function properly, has been included in the QOF since its first year, 2004/05. 

Within the clinical domain of the QOF, the overall percentage of available points achieved was relatively lowest in the depression indicator group, with GMS practices achieving, on average, 95.6% of the 33 points available per practice (up from an average of 94.9% in 2007/08).  However, this still represents a high level of achievement overall.

Amongst the individual health conditions included in the QOF, the biggest improvement in achievement for 2008/09 compared with 2007/08 was observed for the mental health indicator group.  The guidance for mental health changed in 2008/09, although the indicators remained the same.  In 2007/08 this was the clinical indicator group with the lowest achievement levels, with GMS practices achieving on average 94.7% of the 39 mental health indicator points available.  By 2008/09, this had risen to 95.9%.

A slight fall in overall achievement between 2007/08 and 2008/09 was noted for Chronic Obstructive Pulmonary Disease (COPD) which fell from 98.6% to 97.8%.  Care should be taken when looking at the achievement percentage for this indicator group however, since one of the evidence based indicators that make up the indicator group was replaced with a revised one, and the number of points available to each practice fell from 33 to 28.

The overall percentages of points achieved by GMS practices for the clinical indicator groups in 2008/09 were as follows:-

  • Asthma - 98.9%
  • Atrial Fibrillation - 98.6%
  • Cancer - 98.3%
  • CHD - 99.7%
  • Chronic Obstructive Pulmonary Disease (COPD) - 97.8%
  • Chronic Kidney Disease (CKD) - 99.0%
  • Dementia - 99.0%
  • Depression - 95.6%
  • Diabetes - 99.2%
  • Epilepsy - 97.7%
  • Heart Failure - 99.0%
  • Hypertension (high blood pressure) - 99.5%
  • Hypothyroidism - 99.9%
  • Mental Health - 95.9%
  • Palliative care - 97.6%
  • Conditions assessed for smoking status - 99.3%
  • Stroke & transient ischaemic attack - 99.3%

Achievement in the organisational, patient experience and additional services indicator groups were similarly high overall.  Across all practices with GMS contracts, 98.9% of all available points were scored in the additional services domain, which includes indicators relating to cervical screening, child health surveillance, contraceptive services and maternity services.  Similarly, high figures were achieved for the organisational domain (covering record keeping, education and training, practice management and medicines management), with a total of 98.0% of available points scored.  Achievement in the patient experience domain (relating to patient consultations and surveys) was not quite as high, at 88.9% overall.  This is mainly attributable to relatively low achievement in the two new patient experience indicators for 2008/09, PE07 and PE08, as discussed above.

Payments

QOF funding is part of a total of around £705 million invested annually in Primary Medical Services across Scotland.   Payments associated with the QOF for 2008/09 total approximately £128 million, down from roughly £131 million in 2007/08.  These payment figures include a small number of practices whose data are not included in this publication because they have a highly individualised QOF therefore any achievement reported through QMAS isn't a true reflection of their actual achievement.  The total payment figure for practices included in this publication is £126.5 million.  This translates as an average QOF payment of nearly £129,500 for practices with a new GMS contract in 2008/09 compared to £131,000 for 2007/08.  There is, however, a great deal of variation in the amounts paid to individual practices, as the total payment depends not only on how many points each practice achieves but also various other factors including the size of the practice (number of registered patients). The main reasons for the reduction in average payment figures are

  1. the relatively low achievement for PE07 and PE08, discussed above, and
  2. an increase in the Contractor Population Index (CPI).  The CPI is a notional average practice list size that is used, along with an individual practice's actual list size, to calculate a 'population factor' for payment purposes.  All else being equal, a practice with a larger list size (and therefore a larger population factor) will receive a greater payment per QOF point than a practice with a smaller list size.  When the CPI value is increased, as it was for 2008/09, all else being equal practice QOF payments will decrease.

Prevalence

QOF register and prevalence information is shown for all practices for which such data are available, across all practice contract types.  Scotland level prevalence data have already been published in June 2009, based on practice register submissions as used to support payment calculations.  However, more complete, finalised practice register data are now available, based on a higher number of practice returns; these are shown in this publication.  This means that some of the figures provided in this full release may differ from those published in June.

Reported prevalence rates for many of the diseases or health conditions included in the QOF were very similar across Scotland in 2008/09 to the rates reported for 2007/08.  Whilst any comparison of prevalence rates need to be made with caution (see Interpretation section above), the main change in reported prevalence rates between 2007/08 and 2008/09 was for 'new diagnosis of depression'. The overall QOF-reported crude prevalence rate of 'new diagnosis of depression' increased from 6.9% to 7.8%.  However an increase was expected since, even though the indicators attributed to the register measure against new diagnosis, the register itself is effectively for all diagnoses of depression as recorded by a practice (unless the practice has subsequently recorded the depression as having been resolved), meaning that the register is cumulative year on year. 

The QOF-reported prevalence rates for obesity decreased from 7.3% in 2007/08 to 7.0% in 2008/09, much lower than rates reported from other sources.

-----------------------------------------------------------------

MAIN CONTACTS:

Alistair Smith
Information Analyst
0131 275 6784
Alistair.Smith4@nhs.net

Julie Kidd
Principal Information Analyst
0131 275 6450
Julie.Kidd@nhs.net

-----------------------------------------------------------------

GLOSSARY:

GMS - General Medical Services.  This is the main, generic type of contract for general practices in Scotland.  Approximately 87% of Scottish general practices operate under a new GMS contract.  The new GMS contract was introduced on 1st April 2004.

Section 17C.  Formerly known as 'Personal Medical Services' or 'PMS' contract.  This a non-generic type of contract for general practices in Scotland.  The details of the contract can be tailored, e.g. to meet specific needs in the local population.  Approximately 8% of Scottish general practices operate under a 'Section 17C' contract.

2C.  This is another, non-generic type of contract for general practices in Scotland.  The reasons for a practice being a 2C type can vary, but usually this indicates that the practice is being run directly by the NHS Board and that the Board employs the GPs, nurses and other practice staff.  Approximately 4% of Scottish general practices are of 'Section 2C type'.

Holistic care bonus.  This refers to points in pre-2008/09 versions of the QOF that used to reward practices for having consistently high achievement against the clinical indicator groups.

-----------------------------------------------------------------

PRE-RELEASE ACCESS:

Under terms of the "Pre-Release Access to Official Statistics (Scotland) Order 2008", ISD are obliged to publish information on those receiving Pre-Release Access ("Pre-Release Access" refers to statistics in their final form prior to publication). The standard maximum Pre-Release Access is five working days. Shown below are details of those receiving standard Pre-Release Access and, separately, those receiving extended Pre-Release Access.
 
Standard (five day) Pre-Release Access:
Scottish Government Health Department (Analytical Services Division).
NHS Board Chief Executives.
NHS Board Communication leads.
Scottish General Practitioners Committee (part of the British Medical Association).  One day access to SPN only.
 
Extended Pre-Release Access:
Scottish Government Health Department (Analytical Services Division)
This extended Pre-Release Access is given to a small number of named individuals in the Scottish Government Health Department (Analytical Services Division). This Pre-Release Access is for the sole purpose of enabling that department to gain an understanding of the statistics prior to briefing others in Scottish Government (during the period of standard Pre-Release Access).
 
 
-----------------------------------------------------------------

HISTORY OF THIS PUBLICATION:

Last Published: 30 September 2008
Next Due: 28 September 2010
Data Available Since: 2004/05 is the earliest year available as this was the first year for which the QOF existed


Main contact: Email Alistair Smith