NICE indicator programme - frequently asked questions

1. What is the Quality and Outcomes Framework (QOF)?
2. What is NICE's role?
3. Why has NICE been asked to oversee this process?
4. How were the QOF indicators previously set?
5. Why did QOF need to change - has it not worked well since it was introduced in 2004?
6. Expenditure on the QOF is currently about £1 billion in England, or 15% of total spend on primary care. Given NICE's role as a rationing body, is this all about reducing those costs?
7. So how will NICE decide what indicators are included in the final “menu”?
8. What will be the evidence base behind future QOF indicators?
9. Will NICE create a tougher framework than the one that currently exists? i.e. will it be more focused on cost effectiveness than clinical care?
10. There has been criticism of the current QOF indicators because they take a blanket national approach. How will the new arrangements address this?
11. What about patient experience? How will NICE ensure that this is captured when developing and reviewing indicators?
12. How will the process of setting the indicators work?
13. What happens then?
14. How long will this process take?
15. How many indicators will NICE look at each year?
16. How will NICE manage what looks to be a potentially significant increase in its workload?
17. So NICE won't actually be setting the new indicators?
18. How will NICE assess the cost effectiveness of QOF indicators?
19. But what about those interventions with good evidence for clinical effectiveness, but without research on cost effectiveness?
20. When did NICE take over the management of the process of developing and assessing the QOF indicators?

1. What is the Quality and Outcomes Framework (QOF)

Introduced in 2004 as part of the General Medical Services Contract, the QOF is a voluntary incentive scheme for GP practices in the UK, rewarding them for how well they care for patients.

The QOF contains groups of indicators, against which practices score points according to their level of achievement. NICE has been asked to focus on the clinical and health improvement indicators in the QOF, which includes a number of domains such as coronary heart disease and hypertension.

The QOF gives an indication of the overall achievement of a practice through a points system. Practices aim to deliver high quality care across a range of areas, for which they score points. Put simply, the higher the score, the higher the financial reward for the practice. The final payment is adjusted to take account of the practice list size and prevalence. The results are published annually.

The NHS Employers website details the QOF Guidance for the GMS Contract 2009-10. The NHS Information Centre publishes the results online each year.

2. What is NICE's role?

NICE's role is to manage the process to develop the clinical and health improvement indicators for the QOF. This involves prioritising areas for new indicator development, developing indicators, and ensuring consultation with individuals and stakeholder groups.

We will also recommend whether existing indicators should continue to be part of the QOF. For example, where the activity being measured has become part of standard clinical practice, there would no longer be a need to provide a financial incentive.

We will publish the final menu of indicators on our website. Then NHS Employers (on behalf of the four UK health departments) and the BMA will negotiate which indicators should be applied nationally as part of the QOF and what the value and thresholds of the indicators should be.

Our process guide sets out in detail the processes involved in managing the development of indicators for the QOF, which ensure that indicators are developed in an open, transparent and timely way, with input from individuals and stakeholder organisations.

3. Why has NICE been asked to oversee this process?

Currently, QOF indicators do not systematically take cost effectiveness into account. There is evidence that some QOF payments do not currently reflect the value of the indicators, in terms of health benefit. One of NICE's acknowledged key strengths is our robust process for assessing what is both clinically and cost effective for use in the NHS.

It is important that the process for assessing evidence to review or develop QOF indicators is separate from the process for negotiating and approving changes to the QOF. NICE acts independently when producing clinical and public health guidance for the NHS and we will bring this experience to assessing evidence and developing indicators for the QOF.

By overseeing the process of developing and reviewing performance indicators for the QOF, we can ensure that the principles behind our recommendations are reflected in the indicators. This will encourage the implementation of NICE guidance and lead to improvements in care across the UK.

4. How were the QOF indicators previously set?

Previously, the work to develop potential new indicators for the QOF and to advise the negotiating parties on the evidence base was performed by the QOF expert panel. This was a consortium of academic bodies coordinated by the National Primary Care Research and Development Centre (NPCRDC), based at The University of Manchester.

The process involved a call for evidence which was then reviewed by expert groups. Following this, a confidential report was produced for negotiation between NHS Employers (on behalf of the DH) and the General Practitioners Committee (GPC) of the BMA.

5. Why did QOF need to change - has it not worked well since it was introduced in 2004?

The QOF has been very effective in driving quality improvements across primary and community care and in promoting healthy lives.

However, the Darzi report, High Care Quality for All (June 2008) highlighted the need for a more independent and transparent process for reviewing and developing indicators, as well as the need to give practices greater flexibility to select indicators that reflect local health improvement priorities. In addition, a recent National Audit Office report on GP contract modernisation recommended that indicators be based more on outcomes and cost effectiveness.

6. Expenditure on the QOF is currently about £1 billion in England, or 15% of the total spend on primary care. Given NICE's role as a rationing body, is this all about reducing those costs?

Not at all. The overall aim of these changes is to support healthcare professionals in delivering outcomes for patients that are among the best in the world.

In order to achieve this aim, NICE will be at the heart of a process that will ensure that QOF indicators address topics of importance to patients, professionals and the health of the public, and help professionals make the best use of NHS resources. Central to that is the need to ensure that all indicators proposed for inclusion in the QOF are based on evidence of clinical and cost effectiveness. It is important that indicators are reviewed regularly and are able to evolve or be retired - for example, where the activity being measured has become part of standard clinical practice and therefore no longer needs to be incentivised.

7. So how will NICE decide what indicators are included in the final "menu"?

By taking on responsibility for overseeing the process of developing and reviewing performance indicators for GPs, and providing evidence for the Primary Care QOF Indicator Advisory Committee, we can ensure that the principles behind our recommendations are reflected in the QOF. This will encourage the implementation of NICE guidance and lead to improvements in care across the country.

8.What will be the evidence base behind future QOF indicators?

Information on indicators included in the QOF will be compiled by the QOF Indicator Programme team and the NPCRDC/YHEC consortium.

An initial review of all NICE guidance published in the last 3 years (since 2006) has already identified evidence-based clinical and public health recommendations relevant to primary care. During the early stages of the new process this information will be used to inform new QOF indicators.

In the future NHS Evidence will provide accredited sources of evidence for the QOF beyond published NICE guidance. The QOF Indicator Programme team will work closely with NHS Evidence to be aware of newly accredited and forthcoming evidence that may provide the basis of QOF indicators. This will enable future QOF indicators to extend beyond areas where relevant NICE guidance already exists.

9. Will NICE create a tougher framework than the one that currently exists? Will it be more focused on cost effectiveness than clinical care?

New indicators will reflect NICE guidance where that exists and NHS Evidence will soon be able to provide other accredited sources of information. But all the indicators will be based on cost effectiveness as well as clinical benefit. We believe that GPs are already mindful of cost, so they are already concerned about the cost effectiveness of indicators.

10. There has been criticism of the current QOF indicators because they take a blanket national approach. How will the new arrangements address this?

NICE's new role will be to produce a national “menu” of indicators that can be selected depending on local needs. For example, where obesity prevalence is high, local indicators would allow a targeted approach.

11. What about the patient experience? How will NICE ensure that this is captured when developing and reviewing indicators?

All stakeholders, including patients, will be afforded a clear opportunity, through a process of suggesting topics for consideration and through consultation, to contribute to the development of QOF indicators. This could, in the future, include exploring the development of indicators based on patient reported outcome measures (PROMs) for clinical areas.

12. How will the process of setting the indicators work?

The key steps in the process will be:

1. NICE gathers clinical and cost-effectiveness information to help prioritise new indicators. Interested parties submit potential clinical and public health topics for consideration through the NICE website.

2. The independent Primary Care QOF Indicator Advisory Committee prioritises these topics for inclusion in the QOF.

3. The National Primary Care Research and Development Centre (in collaboration with the Royal College of GPs and York Health Economics Consortium) develops the indicators, testing them in a number of GP practices across the UK.

4. NICE consults on the developed indicators, validates the proposals through the Committee and publishes them on the NICE website.

5. Each recommended indicator is accompanied by supporting information, such as review date and the supporting cost-effectiveness evidence.

An interim process guide is available .

13. What happens then?

There is a separate process to decide which indicators should be included in QOF and at what price.

The decision on which indicators are included in the QOF will continue to be negotiated between NHS Employers (on behalf of the four UK health departments) and the BMA.

14. How long will this process take?

The new process, including prioritisation, indicator development, piloting, consultation and validation will take about 18 months. This will be followed by negotiations between NHS Employers and the BMA and any local negotiations between pcts and practices. So the total review cycle would take about 2 years.

15. How many indicators will NICE look at each year?

The intention is that all clinical and health improvement indicators will be reviewed over a period of 3 to 4 years - so 20 to 30 indicators a year. In addition, NICE will aim to develop around 10 new clinical indicators over each QOF review cycle.

16. How will NICE manage what looks to be a potentially significant increase in its workload?

NICE has commissioned an external contractor to review all existing indicators and support the ongoing development of new QOF indicators. The contractor, a consortium representing a collaboration between the National Primary Care Research and Development Centre (NPCRDC), York Health Economics Consortium (YHEC) and the Royal College of General Practitioners (RCGP), is also responsible for applying a methodology for cost effectiveness for all new indicators developed and to produce accompanying guidance, as well as piloting new indicators with practices.

17. So NICE won't actually be setting the new indicators?

No. NICE will manage an independent and transparent approach to produce a national “menu” of approved indicators from which NHS Employers (on behalf of the DH) will negotiate with the BMA on which indicators should be applied nationally in the OQF and what the value of those indicators should be.

18. How will NICE assess the cost effectiveness of QOF indicators?

We have developed a methodology for assessing the cost-effectiveness of QOF indicators, which is detailed in the process guide

19. But what about those interventions with good evidence for clinical effectiveness, but without research on cost effectiveness?

Wherever possible, our advice will be based on evidence of cost effectiveness. Where this is not possible we will develop a transparent approach to assessing the relative value of indicators with good clinical evidence but without evidence of cost effectiveness.

20. When did NICE take over the management of the process of developing and assessing the QOF indicators?

NICE took over this process on 1 April 2009, when the previous QOF expert panel came to an end. There is a transitional process in place in order to produce QOF recommendations for 2010/11. This will involve NICE receiving the reports already published by the QOF expert panel on the recommendations for new indicators and any that were in progress up to the transition point. We will then consult with the Primary Care QOF Indicator Advisory Committee on priorities for review of existing indicators and for the development of new indicators for 2010/11. This truncated process will see published recommendations for the 2010/11 negotiations in August 2009.