From Improving Chronic Kidney Disease (CKD) Management to Improving Incentive Scheme
A personal perspective of kidney health research from NIHR ClAHRC GM’s Facilitator, Claudia Soiland-Reyes
One of my first projects as Facilitator was the AHSN kidney health project. This project aimed to replicate the success obtained in the previous CKD project in two Greater Manchester localities where, with the use of an audit tool and facilitation support, practices improved the accuracy of their Chronic Kidney Disease (CKD) registers and their adherence to best practice CKD guidelines. In the new project the intention was to replicate this model across all Greater Manchester localities; however, something changed during the project planning stage; news came that three out of the four QOF CKD indicators were going to be removed for the next 2015/16 year. At that point, it was agreed we needed to understand the impact of such change in the project. But why should this decrease in the number of QOF CKD indicators be a concern?
Under the General Medical Services contract introduced in 2004, practices get paid for the provision of essential services; for the provision of additional services and an optional incentive for the provision of care according to best practice guidelines: the Quality Outcomes Framework (QOF). Every year a panel reviews the areas of care they would like to incentivise, new areas are added and some others are removed. For a given area a number of best practice indicators are defined and each indicator is allocated a maximum number of QOF points. Finally, a QOF point translates into a payment in pounds. The income received from this incentive could represent up to 25% of a practice total income.For CKD, before the change in 2015/16 practices could get up to 32 QOF points. After this, practices were only required to keep a record of the patients with CKD and for this they could only get 6 QOF points.
To understand the impact of the QOF CKD changes in primary practice, we engaged in a consultation with GPs and with Clinical Commissioning Group leads across all GM. We also did an audit to understand the state of their CKD disease registers. The answers were varied. In some cases interviewees were concerned about the timing of this removal as they considered a knowledge gap still existed around CKD and how to manage it. Some other interviewees thought the removal of CKD indicators wouldn’t affect the care provided in this area; nevertheless a number of interviewees were concerned that the focus would shift to the new QOF incentivised areas.
Based on the conversations we had with the GPs and CCG leads I understood that this concern was not founded purely on financial drivers, GPs expressed their concerns about the external local and national pressures arising from the new expectations from Primary Care. Also, at an operational level, GPs mentioned even if they wanted to keep monitoring CKD as they did under QOF, they would be unable to do so; the tools to track missing checks for CKD patients would disappear as soon as their practice system providers updated the QOF audit plug-ins in line with the new guidance. It became clear that, unless practices implemented their own monitoring systems, it would all be up to the opportunistic checks a GP could sneak in during a ten minutes consultation a patient requested, most likely, for another reason.
The pressures the NHS is facing are felt in every part of the system. National and local commissioners need to prioritise the use of their resources at the same time as promoting best care. Schemes like QOF are important for promoting best care; many GPs would struggle otherwise to keep up to date with the many guidelines released every year. But it is also recognised that resources are limited and these need to be shifted from time to time according to patient need or benefit. However, in this specific project around CKD and kidney health, I struggled to make sense of two aspects:
1) the process NICE uses to remove and add QOF indicators every year, and
2) the gap between incentivising best practice and ensuring sustainability of best practice care once the incentive stops.
While I was writing this blog I came across a document published by NICE about the rationale to identify indicators for removal in the 2016/17 guidance, but nothing as detailed for 2015/16 or the previous years. It was good to find out that some clear criteria had been defined for this purpose in recent years. As to the second point, I don’t know what the solution is, but one very simple thing was evident to me; practices need to have the systems or the skills in order to continue monitoring the retired indicators. I met a practice manager from a practice in Stockport, with an inquisitive and logical mind, who managed to build an audit system for his practice that replicated the retired CKD indicators and also provided real-time alerts to flag missing checks to GPs during a patient consultation. Unfortunately, practices having access to staff with these kind of skills are the exception rather than the rule.
Primary Care practices need all the support they can get; they face shortage of resources and increasing workload. As mentioned by Simon Stevens last October, the QOF scheme is slowly being retired, but whatever scheme replaces QOF, incentive modellers need to consider the factors that must be in place to sustain the improvement once the incentive stops, be this for CKD or in any other area.
 Calculated based on the 2012/13 QOF guidance value per QOF point in England. Source: http://www.medeconomics.co.uk/article/1080916/qof-evolving  EMIS, Vision, System One…  https://www.nice.org.uk/media/default/Get-involved/Meetings-In-Public/indicator-advisory-committee/identifying-qof-indicators-for-review-web-version.pdf