Investing in general practice
February 2003
Chapter 3 : Rewarding quality and outcomes
3.1 Practices already provide a quality service, although the existing GMS contract places far greater emphasis on high volume than quality of care. Less than 4 per cent of the total current spend on fees and allowances is explicitly derived from quality of care. This emphasis runs counter to GPs’ professionalism, the interests of the NHS, and the interests of patients.
3.2 The new contract will address this through introducing a quality and outcomes framework based on the best available research evidence. High achievement against quality standards will bring very substantial rewards. Payments to prepare for entering the quality and outcomes framework will be guaranteed to all practices in 2003/04. Thereafter resources will rise significantly.
3.3 The framework represents the first time any large health system in any country will systematically reward practices on the basis of the quality of care delivered to patients. It is in line with professional opinion and reflects the ethos that higher quality care is most likely to be achieved through the use of incentives.
3.4 This chapter describes:
(i) the contents of the framework
(ii) how payments will be made
(iii) how achievement will be calculated
(iv) monitoring arrangements
(v) review and updating arrangements.
Contents of the framework
3.5 The framework contains domains. Each domain contains a range of areas described by key indicators. The indicators describe different aspects of performance. The four domains are:
(i) clinical domain. This contains ten disease areas:
- coronary heart disease (CHD) including left ventricular dysfunction (LVD)
- stroke and transient ischaemic attacks (TIA)
- hypertension
- hypothyroidism
- diabetes
- mental health
- chronic obstructive pulmonary disease (COPD)
- asthma
- epilepsy
- cancer.
(ii) organisational domain. This contains five areas:
- records and information
- communicating with patients
- education and training
- medicines management
- clinical and practice management.
(iii) additional services domain. This contains four areas:
- cervical screening
- child health surveillance
- maternity services
- contraceptive services.
(iv) patient experience domain. This has two areas:
- patient survey
- consultation length.
3.6 Although the whole practice population will benefit from the range of clinical and organisational standards, older people will benefit particularly from the focus on active management of those patients suffering from stroke, CHD, diabetes and hypothyroidism. Additionally, the new contract will incentivise greater quality of care for children generally through child health surveillance and particularly through the focus on asthma in the quality framework.
3.7 The indicators for each domain are attached at Annex A - read more here. These were developed by an expert group, based on the following principles:
(i) indicators should be based on the best available evidence
(ii) the number of indicators for each clinical condition should be kept to the minimum compatible with an accurate assessment of patient care
(iii) data should never be collected purely for audit purposes. Only data that are useful in patient care should be collected. The basis of the consultation should not be distorted by an over-emphasis on data collection, and an appropriate balance should be struck between excess data collection and inadequate sampling
(iv) data should be obtainable from existing practice clinical systems.
3.8 The clinical indicators are split into three different types:
(i) structure. For example, is a disease register in place?
(ii) process. For example, is the indicator being measured and an appropriate intervention being made, across what percentage of the relevant population?
(iii) outcome. For example, how well is the condition being controlled, across what percentage of the population?
Evidence base
3.9 The evidence base underpinning the indicators is set out in the supporting documentation. The clinical indicators draw on best research evidence.
3.10 Many of the organisational indicators are derived from existing evidence-based schemes such as the Royal College of General Practitioners Quality Team Development and Practice Accreditation Scheme. Practices already delivering the requisite quality standards in line with these and other accredited schemes will have already made considerable progress within the quality framework and will be rewarded accordingly.
3.11 The inclusion of patient experience in the quality framework of the new contract represents an opportunity for practices to obtain systematic feedback from their patients about the services they provide and how they are provided, and to include these in their service development plans as well as engaging patients in service redesign. Many practices are already doing this and there are a number of patient questionnaires in existence. Initially, two questionnaires have, following adaptation, been accredited for use in the new GMS contract:
(i) Improving Patient Questionnaire (IPQ) developed by Exeter University
(ii) General Practice Assessment Questionnaire (GPAQ) developed by the National Primary Care Research and Development Centre in Manchester.
Further information about these questionnaires will be included in supporting documentation.
3.12 Statutory and mandatory requirements that will replace existing terms of service will be set out in the national practice-based contract being developed in line with primary and secondary legislation, and are attached at Annex B.
Making payments
3.13 Three types of payments will be made:
(i) preparation payments (in the first three years only)
(ii) aspiration payments that include additional infrastructure costs but excluding premises and IT
(iii) achievement payments.
Preparation payments
3.14 Implementing the quality framework will take time for practices. In recognition of this, substantial quality preparation payments will be made in 2003/04, 2004/05 and 2005/06. These payments are not conditional on achievement but they will enable practices to collect initial data to establish their current position in the framework. This will assist them in determining their aspiration for achievement in the following year.
3.15 These will be made on a practice weighted population basis using the Carr-Hill formula (see chapter 5). From 2003/04 they amount to an average of £9,000 per practice in each of the three years. They will be paid at the beginning of the financial year (or as early thereafter as practicable in 2003/04, in the event of a yes vote).
3.16 Points will be the currency used to distribute the aspiration and achievement payments within the framework and have been allocated, weighted according to workload, costs and importance, to each of the indicators.
Aspiration payments
3.17 From 2004/05, practices will agree their aspiration with PCOs (see paragraph 3.38(iv)) and aspiration payments will be paid monthly alongside the global sum. These payments will be a third of the predicted total points. Even if the practice thinks it is only scoring a relatively low number of points in 2003/04, it will be free to aim as high as it wishes provided it can demonstrate to the PCO that it has a reasonable chance of achievement.
3.18 For example, if an average practice, which thinks it is scoring about 300 points in total across the framework in 2003/04, is aspiring to 750 points in 2004/05, it would receive an ‘aspiration’ payment for 250 points during 2004/05. This payment will help meet additional infrastructure costs associated with delivering higher quality. To recognise the relative workload involved in delivering high quality care to different numbers of patients, the total practice entitlement to aspiration and achievement payments will be adjusted by practice weighted population using the Carr-Hill formula.
Achievement payments
3.19 Achievement for 2004/05 will then be measured at the beginning of the following year (starting from 2005/06), and an achievement payment will be made. If the practice cited above achieved 750 points in 2004/05, it would receive an achievement payment for the remaining 500 points. However, as there will be no cap on quality, if the practice performed better than expected and achieved 900 points it would receive 650 points as its achievement payment, irrespective of the number of points it aspired to. Equally, if the practice did not perform as well as expected and only achieved 400 points, it would only receive a further 150 points as its achievement payment. In this way repayments will be avoided unless the practice achieves less than a third of its aspiration points. In that situation the overpayment will be deducted from the aspiration payment for the following year.
3.20 At the beginning of 2005/06, the practice will also set out what it is aspiring to in that year, and similarly receive payment for a third of the points for that aspiration during the year, alongside the achievement payment for 2004/05.
3.21 Computer software will be provided in 2003/04 to all practices to enable them to calculate, at any point in time, what they are achieving.
Calculating achievement
3.22 A practice’s entitlement to quality payments will be determined through a quality scorecard, which assigns up to 1,000 points for achievement and 50 points for maintaining improved access. In designing the quality scorecard arrangements, the following principles were borne in mind:
(i) simplicity
(ii) transparency
(iii) voluntarism
(iv) continuous improvement
(v) rewarding breadth of service provision as well as depth
(vi) minimising perverse incentives.
3.23 An appropriate balance has been struck between these principles. Given the pioneering nature of the quality framework and its pricing, the scorecard arrangement will be kept under review. Beyond 2005/06 it may be adjusted in the light of lessons arising from its practical application in consultation and negotiation with the GPC.
Distribution of points
3.24 Figure 2 sets out the distribution of points within each area of the framework in 2004/05 and 2005/06. In 2004/05, based on current average list size, each point will be worth £75 per practice with an average weighted population. In 2005/06, this figure will rise to £120 [6]. In order to calculate their entitlement, practices will need to multiply the number of points aspired to by these values. This sum will then need to be multiplied by the ratio between their weighted practice populations and the average weighted population. Initial estimated weighted practice populations will shortly be made available to practices.
3.25 Each practice will have complete freedom to choose which areas of the quality framework to focus on. To reward breadth of achievement across different areas, practices will also be eligible for holistic care and quality practice payments.
Figure 2 - 2004/05 quality scorecard
 | Totals |
| Clinical indicators | |
| CHD including LVD etc | 121 |
| Stroke or transient ischaemic attack | 31 |
| Cancer | 12 |
| Hypothyroidism | 8 |
| Diabetes | 99 |
| Hypertension | 105 |
| Mental health | 41 |
| Asthma | 72 |
| COPD | 45 |
| Epilepsy | 16 |
| Clinical maximum | 550 |
| Organisational indicators | |
| Records and information | 85 |
| Patient communication | 8 |
| Education and training | 29 |
| Practice management | 20 |
| Medicines management | 42 |
| Organisational indicators maximum | 184 |
| Additional services | |
| Cervical screening | 22 |
| Child health surveillance | 6 |
| Maternity services | 6 |
| Contraceptive services | 2 |
| Additional services maximum | 36 |
| Patient experience | |
| Patient survey | 70 |
| Consultation length | 30 |
| Patient experience maximum | 100 |
| Holistic care payments* | 100 |
| Quality practice payments | 30 |
| Total for clinical, organisational, additional, patient experience, holistic care and quality service | 1,000 |
| Access bonus | 50 |
| Total | 1,050 |
How points are scored
3.26 Points are awarded for depth of quality in particular areas and breadth of achievement across the framework.
Measuring depth of quality
3.27 To score points for the process and outcome indicators in a particular clinical area, a practice must have first achieved the structure indicator.
3.28 Reflecting the key principle of voluntarism whereby clinicians may choose where to focus their energies, achievement against each indicator gives a points score which differs according to the associated workload. Achievement for each process and outcome indicator in the clinical areas is assessed by a percentage. A proportion of the points score for each indicator will be awarded in a direct linear relationship for achievement between the minimum, set at 25 per cent for the clinical indicators, and the maximum set for each indicator based on the evidence for the maximum practically achievable level to deliver clinical effectiveness. For example, if 15 points were available for an indicator with a maximum level of achievement of 85 per cent and the practice had achieved 65 per cent, they would receive 40/60ths of 15 points ie 10 points.
3.29 Achievement for each indicator in the organisational domain, additional services domain (with the exception of the indicator for cervical screening coverage) and patient experience domain is based on a yes/no determination. The full number of points per indicator will be awarded for achieving each one. The total points scored for all the above domains are then added together.
3.30 Practices will be able to exclude certain categories of patients from the calculation of performance, for example:
(i) patients who have been recorded as refusing to attend review who have been invited on at least three occasions
(ii) patients newly diagnosed within the practice or who have been newly registered with the practice, who should have measurements made within three months and delivery of clinical standards within nine months, for example lowering of cholesterol or blood pressure
(iii) patients for whom it is not clinically appropriate, for example those who have an allergy, and other contraindications or adverse reaction, and the terminally ill
(iv) where a patient has given informed dissent to treatment and this has been recorded in the records
(v) where a patient has not tolerated relevant medication
(vi) patients who are on maximum tolerated doses of medication whose levels remain sub-optimal
(vii) where a patient has a supervening condition that makes treatment of their condition inappropriate, for example, cholesterol reduction where the patient has liver disease.
3.31 The PCO will normally expect the practice disease register to be broadly comparable to the overall level of morbidity within the PCO. Further guidance on this will be made available. However, there may be cases where the variation is greater because of practice population characteristics. In wholly exceptional cases, where the differences cannot reasonably be explained, the PCO, in consultation with the Local Medical Committee (or its equivalent) and after discussion with the practice, will be able to rescore the clinical achievement payments on the basis of an adjusted disease register reflecting average PCO morbidity. The practice will have a right of appeal against such a decision.
Measuring breadth of quality
3.32 In order to support the intrinsic nature of general practice a separate holistic care payment will recognise breadth of achievement across the range of different clinical areas. A quality practice payment will recognise breadth of achievement across the organisational, additional services and patient experience domains.
3.33 The scale of the holistic care payment is calculated by considering the proportion of points achieved in each of the 10 clinical areas. The proportion of points achieved for the third lowest clinical area determines the proportion scored of the total holistic care points available.
3.34 For example, if a practice achieves half of the total number of points available in five clinical areas, a third in two, a quarter in another and nothing in the remaining two, the practice will be eligible for one quarter of the total holistic care payment.
3.35 The same approach applies for quality practice payments, which span all the areas within the organisational, additional services and patient experience domains. The proportion of points achieved in the third lowest area determines the proportion scored of the total points available for the quality practice payment.
3.36 Many practices are already achieving the access targets set in England, Scotland and Wales. In recognition of the increase in workload required to deliver good access at the same time as higher quality, practices will be rewarded by a 50 points bonus score if they are achieving the relevant target.
Recording and reviewing arrangements
3.37 In order to measure achievement, practices will have to enter and retrieve high quality information from their practice clinical systems. To qualify for payment, quality framework data will be recordable, repeatable, reliable, consistent and auditable. IM&T systems are required in order to deliver such requirements. Education and training of practice staff will be supported through funded national programmes. UK-wide reporting queries will be developed and the GPC will be fully involved in defining these to meet the requirements of the quality framework and software will be provided to all practices to enable them to calculate how their points will translate into rewards.
3.38 The practice quality review will be founded on the development of a relationship between the practice and the PCO based on the principles of high trust, evidence base, appropriate progression and development within the practice context, minimising bureaucracy, and ensuring compliance with the statutory responsibilities of the PCO. The PCO’s role will be given appropriate underpinning in legislation. Within this the following arrangements will apply:
(i) achievement against the quality framework will be reviewed by the practice providing annual information on its performance, together with a PCO visit to the practice, which will initially take place annually. Over time, visits may become less frequent subject to the mandatory requirements for financial audit. This review will be strongly evidence-based against the agreed national standards set out in the quality and outcomes framework. The practice will submit a single standard return form, which is being developed by the NHSC and GPC and which cannot be extended locally. It will be used for practices to self-evaluate their performance and to provide evidence to substantiate their achievement of the quality standards. Each PCO visit will include a comprehensive review and discussion with clinicians and the practice manager. The visit will avoid disruption to patients or other members of the practice. The LMC (or its equivalent) may be involved in this process at the discretion of either party. The practice costs of preparation for the visit are built into the aspiration element of payments
(ii) the frequency of visits may increase and additional supporting evidence may be required where there is concern around, for example, inaccurate practice information or suspected fraud
(iii) participation in and approval through an accredited organisational quality programme can count towards points on the organisational domain. Existing schemes will be accredited for use in this way, and as a result validated achievement against relevant indicators will be subject to lighter touch monitoring as part of the annual review
(iv) where the practice achieves the standards aspired to, the PCO will confirm the level of achievement funding to be given. The practice will also discuss with the PCO the points to which it is aspiring in the following year. Where the practice fails to achieve the standards aspired to, there will be a discussion as to the action to be taken in the following year
(v) the review will be followed up in writing by the PCO for sign-off by the practice
(vi) PCO-wide achievement against the quality framework will be independently inspected, in England and Wales by the Commission for Healthcare Audit and Inspection and by equivalent organisations in Scotland and Northern Ireland.
3.39 Guidance will advise PCOs how best to manage the quality framework and will be subject to the usual process of consultation and negotiation with the GPC. This will ensure consistency of approach across PCOs, including any necessary training for reviewers. IM&T systems will support the process of contract review and quality review. Practices will be able to appeal against a PCO decision through the appeals mechanisms set out in chapter 7. Read more here.
Review and update
3.40 The quality framework will be reviewed and updated as necessary in the light of changes to the evidence base, advances in healthcare, changes in legislation or regulation and the need for further clarity, or so as to include new areas. These decisions will be based on a review of the quality framework and direct monitoring of the quality standards through PCOs and indirect monitoring through academic research and tracking studies. The benefits of change will be balanced against the benefits of stability.
3.41 An independent UK-wide expert group will oversee the process. The group will consider the latest evidence available and make recommendations to the four Health Departments or their agents and the GPC. It will be the responsibility of the negotiating parties to negotiate any changes to the quality framework, including pricing changes.
6. In line with the Gross Investment Guarantee, if there is an overall underspend on quality the pounds per point could increase.