Quality and Outcomes Framework

The Quality and Outcomes Framework (QOF) is a system for payment of GPs in the UK National Health Service. It was introduced as part of the new General medical services (GMS) NHS contract in April 2004. It is supported by an IT system called QMAS.

The QOF rewards GPs for implementing good practice in their surgeries. The QOF comprises a range of criteria which are grouped into 4 domains: clinical, organisational, patient experience and additional services. The criteria are designed around best practice and have a number of points allocated for achievement. At the end of the financial year the total number of points achieved by a surgery is collated by the QMAS system which then converts the points total into a payment amount for the surgery which takes account of the size of the practice and the number of patients diagnosed with chronic illness.

The QOF system is supervised and audited by NHS Primary Care Trusts (or Health Boards in Scotland), who make the related payments from their budgets.

Participation in the QOF is voluntary for each GP practice but the achievement standards were set so low that most practices participated and got (and continue to get) a considerable additional income through the QOF. In the 2004 contract the practice could accumulate up to 1050 'QOF points' (depending on level of achievement for each of the 146 indicators.

A typical clinical indicator would be the proportion of patients with Coronary heart disease who had cholesterol measured in the previous years. Organisational indicators included such things as practice leaflets and practice staff education.

Converting Points to Cash
In the organisational domain the value of points was proportional to the number of patients registered with the practice. In the clinical domain the value of points was further modified by the prevalence of that condition in the practice - this was measured as the square root of the ratio of the national prevalence. For a typical practice the payment was £77.50 per point in 2004/5 and £124.60 in subsequent years.

Changes in 2006
The GMS contract was revised in April 2006 and, in particular, the QOF was adjusted. The basic structure remains as before, but the clinical domain was extended from 11 to 18 areas and 138 points were reassigned. The total number of points was reduced to 1000 and the 50 points that were previously attainable through as "access points" are now folded into an "access" Directed Enhanced Service (DES).

The areas in the clinical domain are:

coronary heart disease, heart failure, stroke and transient ischaemic attacks, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, epilepsy, hypothyroidism, cancer, palliative care, mental health, asthma. Added in 2006 were dementia, depression, chronic kidney disease, atrial fibrillation, obesity, learning disabilities, smoking.

QOF version 10 was introduced in July/August 2007, these contain mainly minor changes to the system, removing, adding or changing codes in the clinical areas to bring them in line with current guidance (Heart Failure) or to fix typos.

Further changes may occur in 2008 but these are currently subject to negotiation.

Exception Reporting
The level of achievement recorded depends on the GP treating the patients with the relevant complaint. But not all patients are treatable or willing to be treated. In order for the GPs not to lose points on account of circumstances that are outside their control they can exclude those patients from counting towards their achievement by "exception reporting" them. Exeception reporting is allowed for:
 * patients who are refusing to attend;
 * patients for whom chronic disease reporting is inappropriate (e.g. terminal illness, extreme frailty);
 * newly diagnosed or recently registered patients;
 * patients who do not show improvement;
 * patients for whom prescribing a medication is not clinically appropriate;
 * patients not tolerating medication;
 * patients refusing investigation or treatment (informed dissent);
 * patients with supervening conditions;
 * cases where diagnostic/secondary care service is unavailable.