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Focus on Review of the Quality and Outcomes Framework

May 2004

This guidance note has been produced by the General Practitioners Committee to inform you of how the indicators within the Quality and Outcomes framework will be reviewed whilst work is underway to establish a UK-wide Expert Review Group.

This is one of a series of guidance notes on the new contract. We would advise all GPs to read the contract documentation, available here. The GPC has produced a list of frequently asked questions and answers which can be found here.

Current clinical domains
The current disease categories that make up the Quality and Outcomes Framework were selected because they were measurable and there was good, UK-wide evidence of the health benefits likely to result from their inclusion in the framework. In addition, their inclusion was reinforced by the fact that responsibility for ongoing management of the disease is principally that of the GP and primary care team.

In the process of deciding which categories to include, some illnesses were not included even where there was good evidence because of the need to have reliable and measurable successful outcomes that were amenable to computerised scrutiny, in keeping with a high trust model of monitoring.

We believe these are essential criteria to bear in mind when making decisions about what should be included in the Framework, now and in the future.

Absence of particular disease categories
The absence of particular disease categories does not diminish their importance. However, it does confirm that there is no robust clinical data at present. All the evidence to date was very carefully scrutinised by the universities of Aberdeen and Manchester.

Updating the Framework
It has been agreed that the Quality and Outcomes Framework will not remain static and will need to be updated.

The Quality and Outcomes Framework will be reviewed and updated in the light of changes to evidence base, advances in healthcare, changes in legislation or regulation and the need for further clarity, or to include new, evidence-based areas. The document Delivering Investment in General Practice, published by the Department of Health made clear that an independent UK-wide expert group would be established to oversee this process.

Currently the arrangements for the expert group and its terms of reference are under discussion between the General Practitioners Committee, the Departments of Health and the NHS Confederation, but have not yet been finalised.

However, the group will consider all aspects of the Quality and Outcomes Framework, including whether existing indicators should be amended and whether new indicators should be included. To what extent new indicators can be added will depend on the appropriate resources being made available to fund such extra work.

There is a need to balance changes to the Framework, with stability for practices. On that basis, it is not intended that any changes will be made before April 2006, other than in exceptional circumstances e.g. where there is a sudden change in the law that would render a particular indicator inappropriate.

Further information about the expert group, its terms of reference and the arrangements for review will be made available once the details are finalised.

Suggestions for the Framework
Whilst arrangements for the expert group are in progress, any proposals for changes and improvements to the Quality and Outcomes Framework, together with supporting evidence, sent to the GPC will be shared with the Department of Health and the NHS Confederation and will be kept on file until the expert group is convened.

Some Frequently Asked Questions and Answers -
Q Where can I find more information about the evidence base?
A There is more information in the Quality and Outcomes Framework guidance within the supporting documentation. This also includes a number of references that you may wish to look at.

Q How much input will grassroots GPs have on quality indicators?
A Undoubtedly there will be many requests for clinical and organisational areas to be added. This will only happen if they fulfil the principles of the framework and attract genuine additional resources. A UK-wide expert panel will keep the Framework under review and make recommendations to the four Health Departments or their agents and the GPC. Where GPs can help is by producing accurate statistics regarding morbidity via the Quality and Outcomes Framework which will potentially help to make the allocation formula more robust.

Q Our practice has done a lot of work in an area which is not covered by the quality framework. Does that mean it would no longer be financially viable to continue this work under the new contract as we would not be getting paid for it?
A The Framework covers areas where there is a strong evidence base. Clearly, however, there are many patients with clinical conditions that are not related to standards in the Framework. Unless the PCO would like to encourage other initiatives via a "locally enhanced scheme", it is likely that such existing schemes will not continue. How evidence-based is the scheme you are running? We have looked at almost every example of primary care evidence in the development of the Framework and are not aware of any significant clinical areas, with a strong published and verified primary care evidence base that we have omitted.