The Quality and Outcomes Framework (QOF) is a pay-for-performance initiative introduced in 2004 as part of the General Medical Services contract. It links a portion of practice income to the achievement of levels of process and intermediate clinical outcome measures in 10 clinical areas, one of which is diabetes. Achievement in these areas earns “points” and points translate into income for the practice.
Pay-for-performance initiatives have been introduced in a number of countries, but the UK’s QOF is one of the best developed. QOF is the only system under which national, regional, PCT and individual practice data from every part of the country are published annually and made freely available (visit www.qof.ic.nhs.uk).
QOF indicators relevant to the diabetic foot
Since the QOF’s introduction there have been two indicators specifically relevant to the diabetic foot, and these have remained unchanged (NHS Employers and the General Practitioners Committee, 2008). Both are process – rather than outcome – measures. They are:
- Diabetes Quality Indicator 9 (DM9): The percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months. Minimum threshold to earn all available points, 25%; maximum, 90%.
- Diabetes Quality Indicator 10 (DM10): The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months. Minimum threshold to earn all available points, 25%; maximum, 90%.
Achievement of process indicators
The recording of certain process measures on a regular basis underpins good diabetes care. The QOF rewards practices who achieve high levels of recording of diabetes process measures. As can be seen in Table 1, the achievement of these indicators has improved across the board. The foot-related indicators have increased from 78–79% in 2004 to 90–91% in 2007/8 (The Information Centre, 2010).
There is, at present, no QOF clinical indicator to reward action taken on foot screening. However, the following are in line with NICE (2004) guidance:
- If the person’s feet are found to be not at risk of diabetic foot disease (that is, normal pulses and no neuropathy), general foot care information should be given and a re-examination arranged for the following year.
- If the person’s feet are found to be at risk of diabetic foot disease (that is, absent foot pulses or evidence of neuropathy), a referral to the community podiatrist should be made.
- If ulceration is present at screening, or if a person presents with signs of ulceration or foot infection at any other time during the year, an emergency referral should be made to the local multidisciplinary diabetic foot team for the person to be seen within 24 hours.
Exclusions
It is possible for practices to exclude people from QOF processes for reasons including extreme frailty, terminal illness and failure to attend after three invitations during the preceding 12 months (NHS Employers and the General Practitioners Committee, 2008). It has been suggested that practices might use this exclusion process to maximise income (Doran et al, 2006). For the diabetic foot process indicators, the exclusion rates in 2008/9 were 5.6% for DM9 and 5.8% for DM10, respectively (The Information Centre, 2009). These low levels of diabetic foot process indicator exclusions do not support the notion of such “gaming” by practices for this indicator. Furthermore, individual practices with high exclusion rates are identified by QOF and may be investigated by their PCT.
Potential new QOF indicators for diabetes
Only two new diabetes-related QOF indicators are being assessed for 2011, both concern diabetic foot care (NICE, 2010). They are:
- The percentage of patients with diabetes with a record of testing of foot sensation using a 10-g monofilament or vibration (biothesiometer or calibrated tuning fork), within the preceding 15 months.
- The percentage of patients with diabetes with a record of a foot examination and risk classification: low risk (normal sensation, palpable pulses); increased risk (neuropathy or absent pulses); high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer); ulcerated foot within the preceding 15 months.
These indicators, and others not related to diabetes, were put out for consultation between 15 March and 11 April 2010 and are now being piloted. Presumably, a decision as to whether they are to be implemented will be made soon.
Conclusion
Since the introduction of QOF in 2004 there has been evidence of a significant improvement in the recording of foot examination to detect neuropathy and foot pulses. Furthermore, a new indicator to encourage foot risk classification is currently being piloted. However, there is, as yet, no indicator to encourage appropriate referral for diabetic podiatric conditions based on the findings of QOF-supported foot examination. In my opinion, such an indicator is needed.
So, what has QOF ever done for diabetic foot disease? It has increased the number of recorded foot examinations!
