100 years of living science Implementing a Quality and Outcomes Framework in primary care: a UK perspective Dr Shamini Gnani November 2007, Mauritius

Outline of seminar  Background  UK Quality & Outcomes Framework  Financial incentives & doctor behaviour  Break out session

UK National Health Service  £68 billion  8.1% GDP  80% NHS contact = primary care  42,000 family doctors  10,500 general practices

UK policy context  Harold Shipman  Measuring doctors performance  Wide variation  NHS Primary Care  Gate-keeper role  Re-think  Cost containment

General practitioner contract  June 2003  Negotiations different stakeholders  British Medical Association  NHS confederation  Department of Health  April 2004 contract introduced  Essential  Additional services  Quality & Outcomes Framework  24 hour, 365 day cover  performance related pay – one third  Implementation of IT structure  Unique national patient data  Quantify crude disease prevalence

Aims of the Quality and Outcomes Framework  Improve primary care organisational & clinical standards  Reduce morbidity & mortality in key areas  Improve patient experience  Develop primary care services

Quality and Outcomes Framework: domains  Clinical  Long-term conditions  Organisational  medicines management  education & training  Patient experience  length of appointments  patient feedback  Additional services  public health measures e.g. cervical screening

19 clinical areas and 80 indicators  Coronary heart disease  Heart failure  Stroke and transient ischaemic attack  Hypertension  Diabetes  Chronic obstructive pulmonary disease  Asthma  Epilepsy  Hypothyroidism  Cancer  Palliative care  Mental health  Dementia  Depression  Chronic kidney disease  Atrial fibrillation  Obesity  Learning disabilities  Smoking

Examples of diabetes indicators  The practice can produce a register of all patients with diabetes mellitus  The percentage of patients with diabetes for whom there is a record of smoking status in the previous 15 months, except those who have never smoked where smoking status need be recorded only once since diagnosis  The percentage of patients with diabetes in whom the last HbA1c is 7.4 or less (or equivalent test/reference range depending on local lab) in the last 15 months

Performance management  GP performance monitored  financial administrative data sources  Development of QOF data items  may lead to the development of more robust indicators  monitor the quality of care by general practices  Public disclosure  Freedom of Information Act 2005 – GP performance data available  Performance tables – allow public to choose practice based on

Performance management tool  Identify poorly performing doctors  Improve overall performance  Clinical governance  Professional re-accreditation

Incentive schemes  Financial incentives or payment systems  Fee for service  Capitation  Few randomised trials Different methods physicians payment  Complex  Rewards practices with a higher prevalence of QOF specific conditions in patient population  ‘what gets measured gets done’

Quality and Outcomes Framework (QOF) payments  In 2004/05  Average practice score = 958/1050 points  Payment/QOF point = £75  Income = £74,245 (average list size & disease prevalence)  In 2005/06  Payment/QOF point = £  Income = £130,830

Performance related pay  Should there be incentives for providing medical care?  Payment per task done  De-professionalise medical profession ‘Treatment and prevention of CVD is becoming a series of isolated tasks predicated on financial rather than clinical value’  Increase prevalence to increase income

Controversies  Newspaper headlines  Overpaid GPs - earnings of £250k  Empty governments coffers  Costing of the framework  Expected QOF score 73% vs 90%  £300 million overspend  BMA quantifies patient benefits:  8,700 lives over 5 years saved  preventing heart attack and stroke  Expansion  allow healthcare firms to tender for bids

Potential lives saved Maximum lives saved per 100,000Typical maximum payment (£) ACE inhibitors in heart failure308.02,400 Influenza immunisation in over 65s146.03,600 Stop smoking advice and NRT ,440 Screening and treatment of hypertension71.016,920 Aspirin in ischaemic heart disease48.01,320 Warfarin in atrial fibrillation33.00 Statins in ischaemic heart disease13.82,760 Statins in primary prevention2.80

Mechanism to change doctor behaviour  Education  Feedback  Doctor participation  Administrative rules  Financial incentives & penalties  Disclosure of incentives important to maintain trusts among public  Multi-faceted interventions most effective

Conclusions  Will QOF deliver any meaningful health gains?  Could QOF divert GPs from more cost-effective activities? Skewing priorities  Is it fair in division of monies across different practice areas?  Will it skew clinical activity to high workload activities that are only marginally effective to the detriment of cost-effective activities?  Rise in prescribing of statins (> £600 million)

Conclusions  Designed as a payment system  but many other potential uses  changes to QOF – further opportunities  Leverage over hospital costs through referrals  Prescribing costs > £8 billion

Break out session

Break out task  Would a quality and outcomes framework in Mauritius improve primary care?  If so how would it be implemented