1. Quality and Outcomes Framework The national Quality and Outcomes Framework (QOF) was introduced as part of the new General Medical Services (GMS) contract on 1 April 2004. The national Quality and Outcomes Framework (QOF) was introduced as part of the new General Medical Services (GMS) contract on 1 April 2004. Participation by practices in the QOF is voluntary, though participation rates are very high, with most Personal Medical Services (PMS) practices also taking part. Participation by practices in the QOF is voluntary, though participation rates are very high, with most Personal Medical Services (PMS) practices also taking part.

2. QPID The Quality Prevalence and Indicator Database (QPID) was developed by the Prescribing Support Unit (PSU), part of the Health and Social Care Information Centre (HSCIC), on behalf of the Department of Health and in collaboration with NHS Connecting for Health. QPID is derived from the Quality Management Analysis System (QMAS), a national system that uses data from general practices to calculate individual practices’ QOF achievement. The Quality Prevalence and Indicator Database (QPID) was developed by the Prescribing Support Unit (PSU), part of the Health and Social Care Information Centre (HSCIC), on behalf of the Department of Health and in collaboration with NHS Connecting for Health. QPID is derived from the Quality Management Analysis System (QMAS), a national system that uses data from general practices to calculate individual practices’ QOF achievement.

3. QOF Publication The data are being published so that strategic health authorities (SHAs), primary care trusts (PCTs) and practices can see their own achievement in a broader context and in order to make the data widely available. The data are being published so that strategic health authorities (SHAs), primary care trusts (PCTs) and practices can see their own achievement in a broader context and in order to make the data widely available. A full set of QOF tables can be found at http://www.ic.nhs.uk/services/qof A full set of QOF tables can be found at http://www.ic.nhs.uk/services/qof http://www.ic.nhs.uk/services/qof

4. Contents of the framework1 The QOF contains four ‘domains’. Each domain contains a range of areas described by key indicators. The indicators describe different areas of achievement. These are: Clinical Domain: 76 indicators in 11 areas (Coronary Heart Disease, Left Ventricular Dysfunction, Stroke and Transient Ischaemic Attack, Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Epilepsy, Hypothyroidism, Cancer, Mental Health and Asthma) worth up to a maximum of 550 points (52.4% of the total). Clinical Domain: 76 indicators in 11 areas (Coronary Heart Disease, Left Ventricular Dysfunction, Stroke and Transient Ischaemic Attack, Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Epilepsy, Hypothyroidism, Cancer, Mental Health and Asthma) worth up to a maximum of 550 points (52.4% of the total). Organisational Domain: 56 indicators in 5 areas (Records and Information, Patient Communication, Education and Training, Medicines Management, Clinical and Practice Management) worth up to 184 points (17.5% of the total). Organisational Domain: 56 indicators in 5 areas (Records and Information, Patient Communication, Education and Training, Medicines Management, Clinical and Practice Management) worth up to 184 points (17.5% of the total). Patient Experience Domain: 4 indicators in 2 areas (Patient Survey and Consultation Length) worth up to 100 points (9.5% of the total). Patient Experience Domain: 4 indicators in 2 areas (Patient Survey and Consultation Length) worth up to 100 points (9.5% of the total). Additional Services Domain: 10 indicators in 4 areas (Cervical Screening, Child Health Surveillance, Maternity Services and Contraceptive Services) worth up 36 points (3.4% of the total). Additional Services Domain: 10 indicators in 4 areas (Cervical Screening, Child Health Surveillance, Maternity Services and Contraceptive Services) worth up 36 points (3.4% of the total).

5. Contents of the framework2 The QOF also rewards breadth of care through three Depth of Quality Measures: 1. A holistic care payment measures achievement across the clinical domain and is worth up to 100 points (9.5% of the total). 2. A quality practice payment measures overall achievement in the organisational, patient experience and additional services domains and is worth up to 30 points (2.9% of the total). 3. A target level of achievement on patient access to clinical care (access bonus) is rewarded with 50 points (4.8% of the total).

6. Data completeness The QOF was introduced as a component of the new General Medical Services (GMS) contract. Participation by practices is voluntary, though GMS practices participating in the QOF must follow the national QOF framework. The QOF was introduced as a component of the new General Medical Services (GMS) contract. Participation by practices is voluntary, though GMS practices participating in the QOF must follow the national QOF framework. The published tables cover two types of data for England: The published tables cover two types of data for England: 1. Data relating to QOF indicator or domain scores. Scores are presented for 8,576 general practices in England. Scores are presented for 8,576 general practices in England. Includes all practices that had data automatically extracted by the QMAS system in March 2005 and/or submitted additional data adjustments for the year 2004/05 during April to June 2005. Includes all practices that had data automatically extracted by the QMAS system in March 2005 and/or submitted additional data adjustments for the year 2004/05 during April to June 2005.

7. Prevalence 1. Disease prevalence information for each disease within the clinical domain of the QOF. The 8,486 practices included in the prevalence tables cover 99.5% of registered patients in England (based on Prescription Pricing Authority data on patients registered with practices in England, January to March 2005). The 8,486 practices included in the prevalence tables cover 99.5% of registered patients in England (based on Prescription Pricing Authority data on patients registered with practices in England, January to March 2005). Based on general practices where there is at least one disease register figure available within QMAS for March 2005, and where QMAS holds a valid practice list size. Based on general practices where there is at least one disease register figure available within QMAS for March 2005, and where QMAS holds a valid practice list size.

8. Key findings Data on prevalence in 11 disease areas was collected from 8,486 practices in England. The highest recorded prevalence was for hypertension (11.3% of patients registered within these practices). Data on prevalence in 11 disease areas was collected from 8,486 practices in England. The highest recorded prevalence was for hypertension (11.3% of patients registered within these practices).

9. Achievement The average QOF points achieved by general practices was 958.7 points, representing 91.3% of the total 1,050 points available. The average QOF points achieved by general practices was 958.7 points, representing 91.3% of the total 1,050 points available. The average points achieved for the clinical domain was 507.7 points (92.3% of the maximum 550 available). Clinical indicators account for 52.4% of the total 1,050 points available. The average points achieved for the clinical domain was 507.7 points (92.3% of the maximum 550 available). Clinical indicators account for 52.4% of the total 1,050 points available.

10. Overall Achievement The average QOF points achieved by practices in England was 958.7 points, 91.3% of the available points. The average QOF points achieved by practices in England was 958.7 points, 91.3% of the available points. The maximum score of 1,050 points was achieved by 222 practices (2.6%). The maximum score of 1,050 points was achieved by 222 practices (2.6%). The median score was 999.1. The median score was 999.1.

11. Distribution of the total points achieved by practices in England

12. Overall Achievement Overall Achievement SHAs Average number of points achieved by practices within each of the 28 SHAs ranges from a low of 914.0 points (87.0% of points available) to a high of 1,021.8 points (97.3% of points available). Average number of points achieved by practices within each of the 28 SHAs ranges from a low of 914.0 points (87.0% of points available) to a high of 1,021.8 points (97.3% of points available).PCTs Average number of points achieved by practices within each of the 303 PCTs ranges from a low of 672.7 points (64.1% of points available) to a high of 1,039.8 points (99.0% of points available). Average number of points achieved by practices within each of the 303 PCTs ranges from a low of 672.7 points (64.1% of points available) to a high of 1,039.8 points (99.0% of points available).

13. Percentage of total points achieved by SHAs

14. Percentage of total points achieved by PCTs

15. Domain Achievement Average points achieved per practice in the Clinical Domain was 507.7, representing 92.3% of the 550 points available. Average points achieved per practice in the Clinical Domain was 507.7, representing 92.3% of the 550 points available. Average points achieved per practice in the Organisational Domain was 160.7, representing 87.3% of the 184 points available. Average points achieved per practice in the Organisational Domain was 160.7, representing 87.3% of the 184 points available. Average points achieved per practice in the Patient Experience Domain was 93.2, representing 93.2% of the 100 points available. Average points achieved per practice in the Patient Experience Domain was 93.2, representing 93.2% of the 100 points available. Average points achieved per practice in the Additional Services Domain was 34.2, representing 95.0% of the 36 points available. Average points achieved per practice in the Additional Services Domain was 34.2, representing 95.0% of the 36 points available.

16. Percentage of points scored in each domain by practices in England

17. Clinical Domain Achievement The clinical domain has the largest number of points available, 550 from a total of 1,050 (52.4%) available to practices. The clinical domain has the largest number of points available, 550 from a total of 1,050 (52.4%) available to practices. Average points achieved per practice for this domain was 507.7 points (92.3% of the maximum). Average points achieved per practice for this domain was 507.7 points (92.3% of the maximum). Maximum points were achieved by 564 practices (6.6%). Maximum points were achieved by 564 practices (6.6%). Of the 11 disease areas in the clinical domain, practices were most successful at achieving the targets associated with hypothyroidism and coronary heart disease (CHD), and least successful with chronic obstructive pulmonary disease (COPD) and epilepsy. Of the 11 disease areas in the clinical domain, practices were most successful at achieving the targets associated with hypothyroidism and coronary heart disease (CHD), and least successful with chronic obstructive pulmonary disease (COPD) and epilepsy.

18. Distribution of the points achieved in the clinical domain by practices in England

19. Percentage of points scored for each disease area by practices in England

20. Prevalence The publication tables present prevalence for 11 disease areas for 52,833,584 registered patients in 8,486 practices. The publication tables present prevalence for 11 disease areas for 52,833,584 registered patients in 8,486 practices. Prevalence is defined as Prevalence is defined as 100 * (number of patients on disease register on 14 February 2005) (number of registered patients as at 1 January 2005) Co-morbidity To estimate how many patients are affected by at least one of these conditions we cannot simply add the prevalence figures together. Many patients are likely to suffer from co-morbidity, i.e. to have been diagnosed with more than one of these conditions. Work commissioned by the Department of Health, based on a sample of 500 practices, suggests that 32.6% of patients with any of these 11 conditions suffer from co-morbidity in respect of this set of diseases.

21. Limitations of the prevalence data 1. For a patient to be included in the LVD count, he/she must also be a CHD patient. 2. Diabetes register fails to distinguish between type I and type II diabetes. 3. Asthma register only includes patients aged 16 and over. 4. Not standardised for age, sex and ethnicity. 5. By definition, the figures don’t include undiagnosed patients.

22. England prevalence rates for each disease area Disease Area Number of patients National Prevalence Coronary Heart Disease (CHD) 1,893,184 3.6% Left Ventricular Dysfunction (LVD) 230,3210.4% Stroke 782,7331.5% Hypertension 5,973,06211.3% Diabetes 1,766,3913.3% Chronic Obstructive Pulmonary Disease (COPD) 716,5081.4% Epilepsy 312,6040.6% Hypothyroidism 1,153,6402.2% Cancer 270,0330.5% Mental Health 290,9260.5% Asthma 3,073,4015.8%

23. Variation in practice prevalence values for England

24. Variation in SHA prevalence values

25. Variation in PCT prevalence values

26. Prevalence – QOF findings The condition with the greatest variation is hypertension which ranges from 0.0% to 34.6% among practices, from 6.2% to 16.6% at PCT level and from 8.8% to 13.8% at SHA level. The condition with the greatest variation is hypertension which ranges from 0.0% to 34.6% among practices, from 6.2% to 16.6% at PCT level and from 8.8% to 13.8% at SHA level. In general, the conditions with higher mean prevalence show a greater variation. In general, the conditions with higher mean prevalence show a greater variation.

27. Comparison of QOF 2004/05 national prevalence figures, PRIMIS practice based estimates and other published estimates (sometimes adjusted to refer to total population). Condition 2004/05 QOF National Prevalence % PRIMIS 14 OtherestimateSource Coronary Heart Disease3.6 4.0 (IHD) 3.8 Key Health Statistics from General Practice 1998 7 Left ventricular dysfunction0.4 0.6 (Heart failure)0.7 Davies et al (rates for 45 and over applied to 2001 Census population) 10 Transient Ischemic Attack or stroke 1.5 1.0 (Stroke disease)1.8 Health Survey for England 1998 (adult rates applied to 2001 Census populations) 9 Hypertension11.310.28.2 Key Health Statistics from General Practice 1998 7 Diabetes3.32.91.7 Key Health Statistics from General Practice 1998 7 Chronic Obstructive Pulmonary Disease 1.4 4 – 6 4.61.3 Gulsvik 11 Littlejohns 12 (rates for 40-74 age range applied to 2001 Census figures) Key Health Statistics from General Practice 1998 7 Asthma in adults 5.8 7.3 (active asthma)7.77.3 Asthma Audit, National Asthma Campaign 13 Key Health Statistics from General Practice 1998 9

28. Increase in diabetes Note there is a large difference in the figures for diabetes; the QOF prevalence and the PRIMIS estimate are higher than other estimate. This may be due to changes in prevalence since 1998. The apparent increase in diabetes prevalence is 94.1% while the increase in prescription items in England for diabetes over the same period was 75.5% (costs increased by 130.9%). These figures are from the Prescription Pricing Authority. Note there is a large difference in the figures for diabetes; the QOF prevalence and the PRIMIS estimate are higher than other estimate. This may be due to changes in prevalence since 1998. The apparent increase in diabetes prevalence is 94.1% while the increase in prescription items in England for diabetes over the same period was 75.5% (costs increased by 130.9%). These figures are from the Prescription Pricing Authority.

29. Cholesterol CHD 8 The percentage of patients with coronary heart disease whose last measured cholesterol (measured in the last 15 months) is 5 mmol/l or less. The percentage of patients with coronary heart disease whose last measured cholesterol (measured in the last 15 months) is 5 mmol/l or less. Average score per practice in England for this indicator was 71.86%. Average score per practice in England for this indicator was 71.86%. How does performance on this indicator compare with PCT spending on cholesterol reducing drugs? How does performance on this indicator compare with PCT spending on cholesterol reducing drugs?

31. Are statins a waste of money? Apparently no relationship between the volume of statins prescribed in PCTs and PCT performance on CHD8. Possible reasons: Apparently no relationship between the volume of statins prescribed in PCTs and PCT performance on CHD8. Possible reasons: ‘Ecological fallacy’: study at PCT level, loss of detail. PSU intend to continue this study at practice level. ‘Ecological fallacy’: study at PCT level, loss of detail. PSU intend to continue this study at practice level. Failure of patients to take drug once prescription has been cashed. Failure of patients to take drug once prescription has been cashed. Failure of patients to adjust their lifestyle. Failure of patients to adjust their lifestyle. Statins ineffective – unlikely! Statins ineffective – unlikely!

33. Conclusion: There must be factors, other than hypertensive register size, that affect PCT performance on BP2.

34. Conclusion: There must be factors, other than asthma register size, that affect PCT performance on ASTHMA 7.

35. Exception Reporting1 Practices may on occasion exclude specific patients from data collected to calculate QOF achievement scores e.g. 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). Practices may on occasion exclude specific patients from data collected to calculate QOF achievement scores e.g. 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 is a feature of practice contracts in respect of QOF but QMAS will not implement functionality on exception reporting until later in 2005. Exception reporting will not be possible for 2004/05 QMAS data. Exception reporting is a feature of practice contracts in respect of QOF but QMAS will not implement functionality on exception reporting until later in 2005. Exception reporting will not be possible for 2004/05 QMAS data.