NICE set to revise Quality and Outcomes Framework indicators

Abstract

On Aug 10, the UK's National Institute for Health and Clinical Excellence (NICE) published its first menu of new indicators for the Quality and Outcomes Framework (QOF). The QOF, a voluntary pay-for-performance scheme designed to reward UK general medical practices for provision of high-quality care, started in April, 2004. Incentives are paid on achievement of points for clinical indicators, practice organisation, and patient experience, and are devised to challenge practices to improve. Although a voluntary scheme, the QOF provides roughly 15% of practice income and consequently most practices participate. At £1·76 billion over budget in its first 3 years, critics have said that incentives are too easy to achieve. Furthermore, the question of whether a focus on process and crude data collection rather than individualised care improves patient outcomes is yet to be answered. Concerns have been expressed that the system encourages overtreatment, is abused through exception reporting, and creates inequalities rather than tackling them. Of greater concern is that care has not improved in areas not included in the QOF, eg, some aspects of diabetes care. Increased transparency of how indicators are set was called for in the Darzi report, in June, 2008. Until now, both negotiation of changes to QOF and assessment of evidence have been done by the QOF expert panel. Moreover, payments have not been weighted to anticipated health benefits from achievement of indicators. NICE, who took over management of review and development of indicators in April, 2009, is expected to ensure that the process is evidence-based, has more local flexibility, and swing the focus towards patient outcomes and cost-effectiveness. Tougher targets are also expected, which could affect practice income. The role of NICE is to provide evidence-based recommendations, but their participation is also a step to wring more value for money out of a system that is presently costing the NHS £1 billion per year and is yet to prove it can strengthen general practice. General practitioners will need to show that, irrespective of incentives for surrogate endpoints, they can deliver better evidence-based care to improve patient outcomes.