AFA FIAB MIHM MAMS FinstCPD
Independent Healthcare Consultant
Director of Primary Care
National Services for Health Improvement
Steve is a former Royal Navy Officer, and joined the health service as a chief management accountant in 1984. He has worked at all levels of the NHS. He was an associate tutor at the Institute for Health Policy Studies at the University of Southampton and has worked for the professional development committee of the Institute of Healthcare Management
Questions have recently been raised over the future of the Quality and Outcomes Framework (QOF).(1) Criteria being measured have changed year on year, and points have been redistributed.(2) The degree to which further changes are made are not yet known, but it is inevitable that more changes will come.
The QOF was introduced to allow quality payments to be made to practices to reward achieving targets in any given financial year. New clinical domains have been added, such as mental health. As part of the new contract deal, the initial cost per patient was significantly increased in the first couple of years. However, in overall terms the amount that could subsequently be earned has not increased. Instead the quality standards were amended with some organisational standards replaced by clinical ones.(2)
One of the most recent changes has been the removal of the patient experience criteria relating to access, replaced by the use of data obtained from the GP Patient Survey.(3) However, many practices have shown dissatisfaction with the results, saying that they do not reflect what they have experienced in their own practices.
Each practice has a reporting system in place that allows the regular monitoring and measurement of these outcomes. Each year, the primary care trust (PCT) will conduct a visit to the practice to check progress against what has already been reported.
In fact, what has happened is that these visits have become less frequent, and often a practice may not be visited for a couple of years. Sometimes, this visit may be deferred for up to three years, or, alternatively, the visit may be only a brief consultation rather than a full visit. Even if your practice is not chosen for a full review, you need to ensure you have reviewed and updated your procedures, regardless of whether the policy has been altered or not.
Random counter-fraud check
Even though the practice may have been visited by their responsible PCT, it could still be selected at random for an independent audit visit. Only a small percentage of practices are selected for this, but it is probably more important than the usual PCT-managed visit. It is a probity visit, and will ascertain whether any fraudulent claims have been made.
The techniques used will determine that data has been entered when it should have been, and will identify where data has been entered incorrectly. If anomalies are identified, then sums awarded may be adjusted and disciplinary action may even be taken. In many cases, an explanation and acceptance that procedures need to change are sufficient.
It must be remembered that the QOF does account for a significant part of the global sum, which is paid to the practice as part of the contract. Failure to meet any part of the QOF or to have points deducted can easily equate to the cost of a member of staff.
Generally it is accepted that a figure of 5% of practices will be selected for a random review. Where a PCT has less than 20 contractors, it is expected that at least one practice will be reviewed. For larger PCTs, the expectation will be to round up to the selected number, or to include one more practice in the review (rather than one less). The process is designed to be completely random. If a practice has been reviewed more than once in the preceding two years, then it is acceptable to discard this practice and select another one. If your practice is selected in subsequent years, then you should at least query this with your PCT.
Sensitivity and co-operation
The practice should bear in mind that this is a normal procedure and that being selected for a review is not an implication that fraud has occurred. Many PCTs will have already involved the local medical committee (LMC) in the actual selection process to ensure there is complete fairness and transparency in the process.
The practice should remember that the PCT does have separate procedures it can invoke if it believes there is a suspicion of fraud at a practice. This could be done at any time.
The practice should expect to receive a counter fraud check in the first part of the year, in order that it does not clash with a subsequent routine visit made by the PCT late in the year. Some believe this is overpowering and unnecessary – but if the practice is doing everything it is claiming to do, it should not matter when the visit takes place or how many visits it receives.
The PCT should be sensitive to the amount of time required to carry out the visit and the impact on both GP and staff time. It also needs to be sensitive to the normal day-to-day running of the practice at the time of the visit.
When the random check is carried out, it will concentrate on the issues raised by the pre-payment check. As a result, it is inevitable that a visit will need to be made to the practice. However, the length of that visit will be determined by the information available at the practice. A practice should not necessarily worry about what is found at the pre-payment check. Very often, there will be a logical and genuine reason why a variance might be found.
Typically, the check will review significant variances. A variance in prevalence rates that is significantly higher or lower than national or local rates will be reviewed. However, a practice may be running a specialist diabetic clinic on a weekly basis, which has attracted new patients with diabetes. If a practice has used excessive exception reporting, then it must be able to demonstrate that it has taken all the necessary steps to see the patient or can provide a clinical reason why the patient should be excepted.
The practice is expected to state how many points it is aspiring to. Therefore, if the number of overall points is significantly different from this aspiration, this will be questioned. Each month, the activity is reported and so there should be an expectation that figures will be consistent throughout the course of the year.
If there are significant monthly variances, these will be examined. It is accepted that some GPs will concentrate more effort on the QOF at different times of the year, but it is still expected that, since the scheme carries on year on year, the activity reported should be more consistent.
When carrying out the PCT visit, the PCT staff are free to find out from the counter fraud visits those areas that might be at most risk. Under the powers that have been granted under the new contract regulations, they are able to review actual patient records and data. However, they must still abide by the code of practice confidentiality, and data, when reviewed, should be anonymised wherever possible.
It is unlikely that the practice will refuse to take part in a random check. If it does, this will act as a trigger to suggest there might be something wrong. However, the practice may wish to negotiate a different date or time for the visit. This approach is acceptable and may take into account GP or staff holidays. The PCT will involve the LMC in any instance where a practice fails to co-operate. This should normally conclude with an acceptable resolution, which will allow the visit to take place.
If a practice fails to co-operate and there are grounds for suspicion of fraud, then the responsible PCT may contact its designated counter-fraud expert to invoke the necessary visit against the practice. Although the counter-fraud check is random and every practice should expect to receive a visit at least once every three years or so, it must be remembered that, where fraud is suspected, independent checks and visits can take place at any time, and may have no direct relationship with the QOF.
Changes for 2009/10
The organisational domains for the current year still include a large number of achievable points. The most noticeable change is that of the removal of the patient experience criteria. However, even though it is not necessary, many practices are continuing to manage their own inhouse surveys and use this information to compare with national data sets. For many, this has proved to be beneficial with regard to PE7 and PE8 for 2008/2009.
Many have appealed against the national findings and are now agreeing local resolution with their PCTs by submitting and analysing information taken from their own General Practice Assessment Questionnaire. A similar pattern may occur for 2009/10.
1. See http://www.managementinpractice.com/article_17121
2. Department of Health. Developing the quality and outcomes framework: proposals for a new, independent process; consultation response and analysis. London: DH; 2009. Available from: http://www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_096423
3. Department of Health. GP patient survey: guidance for PCTs on QOF patient experience indicators. London: DH; 2009. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati…
Quality Management and Analysis System
Department of Health guidance