2. Quality and Outcomes Framework: new NICE recommendations

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1 Proposed Changes to the GMS Contract 2013/14 1. GP pay and expenses uplift It is proposed GP pay and expenses is uplifted by 1.5%. This increased investment will allow for an average pay increase of up to 1% for GPs and practice staff, in particular, to allow for pay increases for lower paid employed staff, in line with public sector pay policy for 2013/14 and a margin of 0.5% for increases in non-staff expenses. The proposal is to apply 1% to the Global Sum (weighted) and any savings offset against the correction factor and recycled. It is proposed to apply 0.5% to the Global Sum Equivalent (which includes the correction factor). The Welsh Government will be mindful of DDRB recommendations on GP pay and expenses should their recommendations be in excess of 1.5%. Although not part of the GMS Contract negotiations, it is also proposed (in line with England) to transfer the responsibility for paying locum superannuation payments to GP contractors to pay. The intention would be for the monies currently held by Health Boards to be applied to the Global Sum Equivalent (weighted). 2. Quality and Outcomes Framework: new NICE recommendations It is proposed to implement the majority of NICE recommendations for improvements to patient care. The NICE recommendations include improved care for patients with rheumatoid arthritis, diabetes, hypertension, chronic obstructive pulmonary disease, heart failure together with improved support for cancer patients. Details of the proposed new and replacement indicators recommended by NICE are outlined in Annex 1. The proposals address concerns about workload and loss of income as follows: (a) It is proposed not to implement the Hypertension recommendations NM36 and NM37. The introduction of these indictors will be assessed for 2014/15. The existing requirement for physical activity under existing PP2 will remain for 2013/14. (b) It is proposed the thresholds be retained at the 2012/13 level (45% - 80%) for the Hypertension recommendations NM 53 and NM 54 which replaces BP5. (c) The Diabetes Mellitus recommendations NM 27, the COPD recommendation NM 47 and the Heart Failure recommendation NM 48 are predicated on a record of referral to either a structured education programme within 9 months of entry on to the diabetes register; a record of an offer of referral to a pulmonary rehabilitation programme; offer of referral for an exercised based programme. Where these programmes of care are not available in the Health Board GP practices will not suffer a loss of income. 1

2 Guidance will be issued to Health Boards asking them to make the required QOF payment if their programmes of care are not available. (d) In relation to Diabetes Mellitus NM 28, it is proposed guidance is developed to define competency including the scope for a practice nurse to deliver this review. The new and replacement indicators will be partly funded by accepting NICE recommendations for retiring indicators from the Clinical Domain and partly by retirements of indicators from the Organisational Domain. 3. Quality and Outcomes Framework: new lower and upper payment thresholds for 20 indicators Current QOF achievement (based on 2011/12 QOF data) is significantly above the current 2012/13 threshold. In order to retain financial incentive and to encourage improvements in the quality of care, increases to the 2012/13 thresholds are proposed. In setting a new payment threshold concerns about a disproportionate workload required to achieve the additional points in reaching a new upper threshold have been considered. It is recognised a disproportionate workload in treating the most hard to reach patients will also have an opportunity cost in terms of patient care. In order to alleviate the potential for a disproportionate workload, it is proposed the new upper threshold be set at the (median) 50 th centile achievement based on 2011/12 QOF data with the new lower threshold being set at 40 percentage points below the new upper threshold. However, where the new lower threshold is lower than the existing 2012/13 threshold, it is proposed the new lower threshold for 2013/14 be retained at the 2012/13 level. Details of the proposed increase in thresholds are outlined in Annex 2. Setting the new thresholds at the 50 th centile will result in an average 10.8% increase in the upper threshold levels across the 20 indicators and an average 9.1% increase in lower threshold level across the 20 indicators. I can also confirm we are not intending to automatically uplift payment thresholds each year, or each time practices manage to achieve new thresholds. Instead, any proposed increase to thresholds will be based on a careful consideration of workload implications and the potential impact on patient care. The raising of payment thresholds for the remaining fraction indicators will be assessed through the contract negotiations for 2014/ Quality and Outcomes Framework: Organisational Domain The proposed changes to the QOF Organisational Domain are outlined in Annex 3. It is proposed indicators worth 78.5 points which require compliance through either recognised standards of good medical practice or good business practice are discontinued. It is proposed that the 78.5 points to be released 2

3 are used to fund the new QOF NICE requirements [31 points] and a new QOF QP indicator [47.5 points] aimed at improving the care for patients who suffer from a chronic condition and who are predicted to be at significant financial risk of unscheduled admission or unscheduled care. In addition, it is proposed that indicators worth 17 points are transferred to the new Public Health Domain. In relation to the 78.5 points which are proposed to be discontinued, it will be assumed GP practices will continue to meet the requirements of the indicators without financial incentive. We will be discussing with Healthcare Inspectorate Wales (HIW) a general programme of inspection in relation to primary care and the potential for appropriate validation work to be undertaken from 2014/15. Whilst we would not expect work to be undertaken on an annual basis, the final decision on the scope and frequency of any validation work will be determined by HIW. It is proposed to retain indicators worth 59 points. These indicators have a clinical and patient safety focus. It is proposed to retain the current Patient Experience Domain. 5. Quality and Outcomes Framework: Quality and Productivity Domain The proposed changes to the QOF Quality and Productivity Domain are outlined in Annex 4. It is proposed discontinuing QP12, 13,and 14 Accident and Emergency Attendances [ worth 31 points] given the potential overlap with the proposed new indicator for patients who are suffer from a chronic condition and who predicted to be a significant risk of unscheduled hospital admission or unscheduled care. It is proposed the 31 points are applied to Global Sum Equivalent (weighted). It is proposed to introduce a new QP indicator [QP 15, 16,17and 18] for patients who have a chronic condition and who predicted to be a significant risk of unscheduled hospital admission or unscheduled care. The new indicator, worth 47.5 points, is funded from discontinued Organisational Domain indicators. Concerns about the prevalence of chronic conditions in Wales have been addressed through the proposal for a maximum of 0.5% of the practice list to be applied for QP16. The guidance for this the new indicator is currently being drafted and will provide clarity on a number of practical points including the number of meetings to be held with multidisciplinary professionals. 6. Quality and Outcomes Framework: A new Public Health Domain It is proposed a new Public Health Domain will apply to Wales in line with national proposals. The proposals, broadly, involve moving indicators (worth approximately 15% of current QOF points) which are related to public health into a new Public Health Domain. The Public Health Domain would continue 3

4 to operate as an integral part of QOF within the GP contract. The priorities for the Public Health Domain would from April 2013, will be decided by PHE, in consultation with the Devolved Administrations 7. Quality and Outcomes Framework: Review dates No changes to the QOF review dates are proposed. The decision not to implement the proposed changes to the QOF review dates reflects GPs workload concerns and the potential impact on GP access. Although there is no evidence of clustering of activity in the last quarter of a financial year concerns expressed about duplication of payment will be addressed through proposed post payment verification checks which will be undertaken by NHS Wales Shared Services Partnership Wales. In addition, it is proposed Health Boards will be asked to monitor the time elapsed between the first and second review as part of their QOF validation work and to consider the impact of exception reporting using a general exception code. Note however, the decision not to implement the QOF review dates changes will be dependent on the capacity for software suppliers to apply different business rules for Wales within required timescales and reasonable costs. 8. Consideration of the need to reduce the variability of funding between GP practices The Welsh Government and GPC Wales agree there is a need to consider reducing the variability of funding between GP practices and that the funding requirements for some practices, in particular, GP practices with multiple sites, rural practices and small GP practices may not be best met through the current allocation formula. In order to address the variation of funding between GP practices, work will be undertaken in 2013/14 involving the Welsh Government, Health Boards and GPC Wales, to consider the scope for introducing changes to practice funding which recognises the different size and location of GP practices and variation in patient weighted funding. Any agreed changes to practice funding will need to be introduced over an agreed timescale, be transparent and be modelled at an individual practice level and must ensure practice financial viability together with providing on-going high quality primary care. There is recognition there may be a situation with extreme outliers that cannot be resolved within a national allocation formula and may need alternative nationally negotiated solutions. 9. Adjustment to the Contractor Population Index (CPI) It is proposed to amend the anomaly in relation to the Contractor Population Index (CPI) by basing the Index on the actual practice size list at the start of the financial quarter before the financial year in question. The intention is to undertake the index rebasing annually and to revalue QOF points. 4

5 Annex 1 Proposed New Indicators Area ID Indicator wording Thresholds Points Diabetes Mellitus NM27 The percentage of patients newly diagnosed with diabetes in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months of entry on to the Diabetes Mellitus NM28 diabetes register The percentage of patients with diabetes who have a record of a dietary review by a suitably competent professional in the preceding 15 months COPD NM47 The percentage of patients with COPD and Medical Research Council (MRC) Dyspnoea Scale 3 at any time in the preceding 15 months, with a subsequent record of an offer of referral to a pulmonary rehabilitation programme Heart Failure NM48 Diabetes Mellitus Diabetes Mellitus Rheumatoid Arthritis Rheumatoid Arthritis NM51 NM52 NM55 NM56 The percentage of patients with heart failure diagnosed within the preceding 15 months with a record of an offer of referral for an exercise based rehabilitation programme The percentage of male patients with diabetes with a record of being asked about erectile dysfunction in the preceding 15 months The percentage of male patients with diabetes who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 15 months The practice can produce a register of all patients aged 16 years and over with rheumatoid arthritis The percentage of patients with rheumatoid arthritis aged years who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 15 months N/A

6 Rheumatoid Arthritis Rheumatoid Arthritis NM57 The percentage of patients aged years with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 27 months NM58 The percentage of patients with rheumatoid arthritis who have had a face to face annual review in the preceding 15 months COPD NM63 The percentage of patients with COPD and Medical Research Council (MRC) Dyspnoea Scale 3 at any time in the preceding 15 months, with a record of oxygen saturation value within the preceding 15 months Total points new indicators points Proposed Replacement Indicators Area ID Replacing Indicator wording Threshold Points CVD Primary NM26 PP1 In patients with a new Prevention diagnosis of hypertension aged years, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an agreed risk assessment tool) of 20% in the preceding 15 months: the percentage who are currently treated with statins (unless there is a contraindication) Depression NM49 DEP 1&6 The percentage of patients with a new diagnosis of depression in the preceding 1st April to

7 31st March who have had a bio-psychosocial assessment by the point of diagnosis Depression NM50 DEP 7 The percentage of patients with a new diagnosis of depression (in the preceding 1 April to 31 March) who have been reviewed within days of the date of diagnosis Hypertension NM53 BP5 The percentage of patients under 80 years old with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 140/90 or less Hypertension NM54 BP5 The percentage of patients with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 150/90 or less Diabetes Mellitus NM59 DM13 The percentage of patients with diabetes who have a record of a urine albumin:creatinine ratio test in the preceding 15 months Stroke NM60 Stroke 8 The percentage of patients with a stroke shown to be nonhaemorrhagic, or a history of TIA whose last measured total cholesterol (measured in the preceding 15 months) is 5mmol/l or less Blood pressure NM61 Records 11& 17 The percentage of patients aged 40 years and over with a blood

8 pressure measurement recorded in the preceding 5 years Cancer NM62 Cancer 3 The percentage of patients with cancer diagnosed within the preceding 15 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis Diabetes Mellitus CVD Primary Prevention NA DM15 The percentage of patients with diabetes with a diagnosis of nephropathy (clinical proteinuria) or microalbuminuria who are treated with ACE inhibitors (or A2 antagonists) NA CVD PP2 The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: smoking cessation, safe alcohol consumption and healthy diet Mental Health NA MH10 The percentage of patients on the register who have a comprehensive care plan documented in the preceding 15 months agreed between individuals, their family and/or carers as appropriate Total Points replacement indicators 139 Total number of Points required for new and replacement indicators 196 8

9 Points released by retirements Retirements due to replacement QOF ID 12/13 Points NICE indicator wording NM26 replaces PP1 8 In those patients with a new diagnosis of hypertension aged years, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an agreed risk assessment tool) of 20% in the preceding 15 months: the percentage who are currently treated with NM45 replaces Cancer 3 statins (unless there is a contraindication) 6 The percentage of patients with cancer diagnosed within the preceding 15 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis DEP 1 6 The percentage of patients on the diabetes register and/or the CHD register for whom case finding for depression has been undertaken on 1 occasion during the preceding 15 months using two standard screening questions NM49 replaces DEP6 NM50 replaces DEP7 NM53 replaces BP5 NM54 replaces BP5 NM59 replaces DM13 NM60 replaces Stroke 8 NM61 replaces Records 11 NM61 replaces Records The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have had a bio-psychosocial assessment by the point of diagnosis 8 The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have been reviewed within days of the date of diagnosis 55 The percentage of patients under 80 years old with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 140/90 or less The percentage of patients with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 150/90 or less 3 The percentage of patients with diabetes who have a record of an albumin:creatinine ratio (ACR) test in the preceding 15 months 5 The percentage of patients with a stroke shown to be non- haemorrhagic, or a history of TIA whose last measured total cholesterol (measured in the preceding 15 months) is 5mmol/l or less 10 The percentage of patients aged 40 years and over with a blood pressure measurement recorded in the preceding 5 years 5 9

10 DM15 3 The percentage of patients with diabetes with a diagnosis of nephropathy (clinical proteinuria) or microalbuminuria who are treated with ACE inhibitors (or A2 antagonists) CVD PP2 5 The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: smoking cessation, safe alcohol consumption and healthy diet MH 10 6 The percentage of patients on the register who have a comprehensive care plan documented in the preceding 15 months agreed between individuals, their family and/or carers as appropriate Total 137 Retirements QOF ID 12/13 Points Indicator Wording CHD10 7 The percentage of patients with coronary heart disease who are currently treated with a beta-blocker CKD2 4 The percentage of patients on the CKD register whose notes have a record of blood pressure in the preceding 15 months DM10 3 The percentage of patients with diabetes with a record of neuropathy testing in the preceding 15 months DM2 1 The percentage of patients with diabetes whose notes record BMI in the preceding 15 months DM22 1 The percentage of patients with diabetes who have a record of estimated glomerular filtration rate (egfr) or serum creatinine testing in the preceding 15 months EPILEPSY 6 4 The percentage of patients aged 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the preceding 15 months BP4 8 The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding nine months Total 28 NICE recommendations for QOF: point calculations Points Points required for new indicators 57 Points required for replacement indicators 139 Total points required 196 Points available from retirements due to replacement 137 Points available from retirements 28 Total points available from clinical domain 165 Points required from organisational domain 31 10

11 Annex 2 Proposed Increases in Thresholds for 2013/14 ID in UEA research ID 2011/12 ID 2012/13 ID 2013/14 Existing 2012/13 thresholds Proposed 2013/14 thresholds lower upper lower upper CHD6 CHD6 CHD6 CHD CHD8 CHD8 CHD8 CHD CHD9 CHD9 CHD9 CHD CHD12 CHD12 CHD12 CHD CHD CHD14 CHD14 CHD /11 STROKE1 STROKE1 STROKE STIA STROKE9 STROKE1 STROKE1 / STIA *BP5 BP5 BP5 HYP DM15 DM15 DM15 DM DM18 DM18 DM18 DM DM6/7 DM26 DM26 DM DM6/7 DM27 DM27 DM DM6/7 DM28 DM28 DM DM12 DM30 DM30 DM DM12 DM31 DM31 DM COPD8 COPD8 COPD8 COPD LVD3 HF3 HF3 HF CKD3 CKD3 CKD3 CKD AF3 AF3 AF6 AF SMOKE2 SMOKE4 SMOKE6 SMOK * Note : The BP 5 indicator relates to NM 54 (150/90 bps ) The payment threshold for both NM 53 and NM 54 are maintained at 2012/13 levels ( 45/80 ) 11

12 Annex 3 Proposed changes to the QOF Organisational Domain Indicators to be discontinued Points R8 Recording drug allergies / adverse reactions in the notes 1 R9 Identification of repeat medicines in records 4 R19 80% of new patients have up to date clinical summaries within 8 7 weeks R20 Up to date clinical summaries for 70% of records 12 E8 Practice employed nurses have Personal Learning Plans and 5 subject to annual appraisals E9 Practice employed non clinical team members have an annual 3 appraisal PM2 Arrangements in place to back up computer data 1 PM3 The Hep B status for doctors and relevant practice staff is recorded 0.5 and immunisation recommended if required PM7 System to ensure regular inspection of equipment. 3 PM10 Written procedure manual covering employment policy 2 E1 Record of practice staff attending life support training in the 4 preceding 18 months E5 Record of practice staff attending life support training in the 3 preceding and 36 months R15 Up to date clinical summaries for 60% of records 25 R18 Up to date clinical summaries for 80% of records 8 Total points discontinued 78.5 Indicators to be transferred to the Public Health Domain Points R11 R17 I 5 Blood pressure of patients aged 45 years and over is recorded in 10 the preceding 5 years for at least 65% of patients Blood pressure of patients aged 45 years and over is recorded in 5 the preceding 5 years for at least 80% of patients Practice supports smokers in stopping smoking by a strategy which 2 includes providing literature and offering appropriate therapy. Total points transferred to the Public Health Domain 17 Indicators to be retained Points R3 System for transferring / acting on information about patients seen 1 by other doctors OOH R13 System to alert OOH services / doctor to patients dying at home 2 E6 Practice conducts annual review of patient complaints 3 E7 12 significant reviews undertaken in last 3 years 4 E10 Practice has undertaken at least 3 significant event reviews within the last year 6 12

13 PM5 Minimum appointment times 3 PM9 Protocol to identify carers 3 PM1 Health professionals have access to information on local 1 procedures dealing with child protection MM 2 Practice has equipment and drugs to treat anaphylaxis 2 MM 3 System for checking expiry dates of emergency drugs 2 MM4 Availability of prescription within 72 hours 3 MM6 Practice meets with PCO prescribing advisor annually and agrees 4 3 actions MM8 Collection of prescription within 48 hours 6 MM10 Practice meets with PCO prescribing advisor annually and agrees 4 3 actions and provides evidence of change MM11 Medication review is recorded in notes in preceding 15 months for 7 patients who are prescribed 4 or more repeat medicines MM12 Medication review is recorded in notes in preceding 15 months for 8 all patients who are prescribed repeat medicines Total points to be retained 59 Summary of Changes to Organisation Domain Total number of points Points discontinued : applied to fund NICE 31 Points discontinued : applied to fund new QP indicator for chronic 47.5 conditions Points transferred to Public Health Domain 17 Indicators retained 59 13

14 Proposed changes to the QOF Quality and Productivity Indicators Annex 4 Indicators to be discontinued Points QP12 Accident and Emergency Attendances - review data 7 QP13 Accident and Emergency Attendances - participate in 9 external review QP14 Accident and Emergency Attendances - implement 15 improvement plan Total points to be discontinued 31 The discontinued points to be transferred to Global Sum Equivalent (weighted) Existing indicators to be retained Points QP6 The practice meets internally to review the data on 5 secondary care outpatient referrals provided by the PCO QP7 The practice participates in an external peer review with a 5 group of practices to compare its secondary care outpatient referral data either with practices in the group of practices or with practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO QP8 The practice engages with the development of and follows 3 11 agreed care pathways for improving the management of patients in the primary care setting (unless in individual cases they justify clinical reasons for not doing this) to avoid inappropriate outpatient referrals and produces a report of the action taken to the PCO no later than 31 March 2014 QP9 The practice meets internally to review the data on emergency admissions provided by the PCO 5 QP10 The practice participates in an external peer review with a 15 group of practices to compare its data on emergency admissions either with practices in the group of practices or practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO QP11 The practice engages with the development of and follows agreed care pathways (unless in individual cases they justify clinical reasons for not doing this) in the management and treatment of patients in aiming to avoid emergency admissions and produces a report of the action taken to the PCO no later than 31 March 2013 Total points 68.5 Proposed new indicators QP15 The practice produces a list of 5% of patients in the practice 10 who are predicted to be at significant risk of unscheduled admission or unscheduled care. QP16 The practice identifies a minimum of 10% ( with a maximum 10 14

15 of 0.5% of the practice list ) of those patients from the list produced in indicator QP15 who would most benefit from review and ensures there is an active management plan (see template attached) in place for each patient. The active management plan must include an appropriate review date. The frequency of each patient's review should be determined in light of their clinical and care needs. The practice will be responsible for ensuring that an appropriate system is in place for monitoring and review of the patients identified QP17 The practice has at least four meetings during the year to 22.5 review the needs of the patients identified as a result of developing the active management plans, to identify learning needs and related changes in patient management. These meetings should be open to multi-disciplinary professionals who support the practice's patients. QP18 The practice reports annually to the CCG or PCO on system 5 changes that may benefit patients Total points 47.5 Points funded from discontinued Organisational Domain indicators New Total QOF QP points 116 Retained existing indicators ( 68.5 points ) and new risk profile indicators ( 47.5 points) Summary of Changes to Quality and Productivity indicators Total number of points 99.5 Points discontinued 31 New indicator : funded from Organisation Domain 47.5 Indicators retained