Helping to provide high quality care in primary care.

THE QOF

On 1 April 2009, the National Institute of Health and Clinical Excellence (NICE) took over a new role in advising on new indicators for the NHS Quality and Outcomes Framework (QOF) in the United Kingdom. Confirmation of this change came at the end of a Department of Health consultation with patients, carers, NHS professionals and commissioners on how the process should work. The move is a strong endorsement of NICE's expertise, gained over 10 years of producing evidence-based guidance.

A crucial part of the new process is the creation, by NICE, of an independent Primary Care Quality and Outcomes Framework Indicator Advisory Committee, which will review existing indicators and recommend new ones. [The committee will be chaired by Dr Colin Hunter who has worked as a General Practitioner in Aberdeenshire for over 20 years. Dr Hunter takes up his post having already held a number of high profile positions, including Chairman of the Scottish Council of the RCGP (1996 – 2000) and as National Co-ordinator of Primary Care for NHS Education Scotland (1995 – 2005). Dr Hunter was also heavily involved in the original version of the QOF, helping to draw up the original outline scheme for the framework which was then proposed to the profession in 2003.] The membership of the committee, finalised in May 2009, includes individuals with experience of primary care, (including GPs and nurses) as well as patients, carers and social care professionals drawn from Northern Ireland, Scotland and Wales as well as England (table I). The process is outlined in table II. Involvement of the devolved administrations in the new process is very important for the changes proposed for the QOF to have the optimal impact throughout the UK. NICE is currently discussing how this might best be achieved in relation, for example, to piloting the indicators in a Northern Ireland context.

Table I

NICE guidance is a primary source of advice on effective clinical and public health practice in the United Kingdom. It forms part of the healthcare standards in England and Wales and is generally adopted in Northern Ireland but selectively applied in Scotland.

	England	Wales	Northern Ireland	Scotland
Technology Appraisals	✓	✓	NICE guidance is generally disseminated after local review	NICE guidance is generally disseminated after local review
Interventional Procedures	✓	✓	✓	✓
Clinical Guidelines	✓	✓	NICE guidance is generally disseminated after local review	-
Public Health	✓		NICE guidance is generally disseminated after local review	NICE guidance is generally disseminated after local review

Table II

The QOF indicators process

QOF indicators process flowchart
Stakeholders submit potential clinical and public health priority topics via the NICE website
NICE collates information to prioritise new indicators based on evidence of clinical and cost-effectiveness
Independent Advisory Committee considers topics for inclusion in the QOF
NICE consults on developed indicators
Advisory Committee validates the final proposals
Recommendations published on the NICE website
NHS Employers, on behalf of the Department of Health, and the British Medical Association (BMA) decide on final indicators to include in the QOF

While QOF indicators have served to improve the quality of primary and community care, and encouraged patients to make health changes in their lifestyles, the QOF needed to change. The Next Stage (Darzi) Review highlighted a need for a more open, transparent process for reviewing and developing the indicators it uses. A recent National Audit Office report on GP contract modernisation recommended that indicators should be based more on outcomes and cost effectiveness than they are at present.

THE NEW PROCESS

Decisions on QOF indicators have not up to now been informed by systematic information on the cost effectiveness of the interventions under consideration. There is evidence that some QOF indicators may not always reflect the value of the indicators in terms of health benefit. This is why NICE is to oversee a new, independent, objective system for the development of new indicators and the review of existing ones. The system will be based on evidence of clinical and cost effectiveness using the same methodological approach that informs our other guidance products.

Because NICE is independent, patients, carers, professionals and other stakeholders can have confidence in the new process, which separates the assessment of the evidence for reviewing and developing potential new QOF indicators from the negotiation and approval of changes to the QOF. Moreover, the new committee will meet in public so that anyone with an interest in the process can both see, and hear, how the indicators emerge. It is important to emphasise, however, that NICE's role is an advisory one. The final decision on which new indicators should be retained, which should be removed, and which new ones should be included, will still be made by NHS Employers, on behalf of the Department of Health, and the British Medical Association (BMA). NICE will therefore produce an annual ‘menu’ of evidence-based, cost-effective indicators. Evidence of clinical effectiveness will be looked at initially using NICE guidance, but will also in time draw upon a range of accredited sources of evidence through the new NHS Evidence service. Where cost effectiveness information it is not readily available, a method for drawing some basic conclusions will be used to assess the indicator.

AN OPEN AND TRANSPARENT PROCESS

It is important to ensure that the process is informed by stakeholders with experience of primary care. As part of the open and transparent process, consultation documents containing the proposals – ranging from proposed topics for indicators to how they have been developed – will be available to all stakeholders (including patients). Anyone can submit possible clinical and public health indicator topics on the NICE website. The Advisory Committee will then use agreed criteria to prioritise topics based on evidence of clinical and cost effectiveness. An external organisation, appointed by NICE, will then develop potential new indicators to be considered by the independent Advisory Committee and with the results of piloting and consultation. The total review cycle will take around two years but a rolling programme will ensure there are new indicators available each year. At the moment there are 88 indicators. These will be reviewed over the next three to four years, so NICE will be reviewing 20 to 30 a year, in addition to a commitment to develop around 10 new indicators over each QOF review cycle.

High-quality care depends on making decisions based on the best available evidence. Placing NICE at the heart of the process will ensure that QOF continues to help ensure patients get the healthcare that is among the best in the world.