Osteoporosis quality and outcomes framework

In November 2011 it was announced that osteoporosis would be included in the quality and outcomes framework (QOF) for general practice (GP) in the UK. Will this make any difference? For the international reader the answer is probably none at all but within the health system of the UK it just might. The reason being that it will financially encourage primary care to pay more attention to this disease area.

Primary care funding within the national health service (NHS) is complex. For anyone who is not a GP the details are likely to baffle and bore in equal measure. Some explanation is however justified in order to determine whether this will be a mechanism for promoting better care of women at and beyond menopause.

General practices are usually small to medium sized, independent businesses contracted to provide services to the NHS. Payment to practices has elements that recognize the numbers of registered patients with an adjustment for deprivation, payments for ‘enhanced services’ that are over and above the core job of the GP and quality payments for meeting targets in defined clinical or organizational areas.

In April 2008 osteoporosis was included in the primary care funding envelope as a designated enhanced service (DES). This funding stream encouraged practices to do extra things that they would not have done before (a ‘carrot’ approach). In return for the additional money the regulation at the time stipulated that:

Practices will be expected to compile an audit of:

If the proportion of patients in each these categories who had been investigated and/or treated met the targets set, then the practices received very modest payments. Among the problems with this was that the payment was small yet the work was significant initially as whole systems needed to be established. In addition, the list of recognized bone sparing agents did not include estrogen and there was no attempt to incentivise primary prevention. The value of the DES was that, in order to make it work, local clinical pathways were evaluated and fracture liaison services and bone mineral density assessment became more generally available.

Many practices looked at the DES and decided that the remuneration offered did not justify the work involved: it was not universally accepted. As a result of the latest round of negotiation, this DES will cease to be available at the end of March 2012 and the extra money it provided will be absorbed back into the general medical services (GMS) pool. Osteoporosis as an issue, however, will now become one of the priority clinical areas addressed by QOF.

The QOF was an innovation of the revised GMS contract of 2004. It aimed to define standards of good practice and then measure performance against pre-set targets with upper and lower thresholds of achievement. If the upper target is met then the value of the allocated points is paid to the practice. The monetary value of each point will be determined by the size of the population involved and therefore, while large practices will have to do more, they will be paid proportionately.

The QOF was seen by the Department of Health as a means to encourage good clinical care. They were initially surprised by how well GP performed against the targets set. It cost them more than they had allowed for. This was no surprise to GP leaders who are essentially innovative and resourceful businessmen and women. Once the Department of Health metaphorically had its fingers burnt, the QOF became more of a management tool. It changes slightly each year with objectives that are both clinical and political and is one element of the overall package negotiated with the general practitioners committee (GPC) representatives.

One innovation of the coalition government is that the disease areas and targets are now determined by National Institute for Health & Clinical Excellence and subjected to consultation in order that clinical priorities are addressed. As might be imagined there is much lobbying for inclusion. Against this background osteoporosis has done well to be included in the QOF for the first time in the year 2012–2013. Other indicators have been ‘retired’ and the practices they encouraged now regarded as ‘core’.

How much of a good thing is this for the world of menopause care?

For an average sized practice (6330 registered patients) a QOF point is worth £130.51 in the 2011–2012 financial year. It will rise by 0.5% in April 2012. To meet all three indicators at the maximum threshold would earn the practice £1180. This is not a huge amount of money in the scheme of things. Practices will still have to decide whether it is enough to justify the effort involved. By the inclusion of osteoporosis in the QOF, however, if the practice were not to meet the target it would effectively be losing potential income. The emphasis has changed. Most will aim at all nine points even though this is less than 1% of the total available under QOF. It has become a ‘stick’” approach and is highly effective.

There has been no rise in the total amount of money available to general practice for some years. Therefore it becomes more important that what is available is earned and claimed. The osteoporosis targets will encourage a focus on secondary prevention of fracture whether the practice was previously interested or not. Awareness of osteoporosis as a condition should rise and the QOF can be expected to improve the clinical care of those who have already sustained a fragility fracture. This is what it is intended to do.

There is still no direct inducement to look at primary prevention. As an optimist one can only hope that raising awareness of the miseries of osteoporosis will encourage the reflective GP to identify a ‘doctor's educational need’ (DEN) when considering his revalidation requirements and learn how this condition might be prevented. Primary prevention of osteoporosis currently requires good clinical care at the level of the individual and lateral thinking by the clinician. Any population measure in primary care at the current time could only be driven by altruism as the cost would be borne by the profit sharing partners of the practice.

Primary prevention needs to become a public health initiative and an element of a risk assessment across a range of chronic disease areas at menopause/midlife. Both the British Menopause Society and International Menopause Society have called for the introduction of such a review. In the UK there has been a proposal to fund vascular checks to identify risks for cardiovascular disease. There has been no such proposal for osteoporosis. While highly desirable it is obvious that this is unlikely to happen in the current financial environment.

So what can we do? The first task is to argue for the inclusion of estrogen as a recognized bone sparing agent. The National Osteoporosis Society has rehabilitated hormones. While clinically appropriate it is still not on the list that the computerized audit tool searches for. Any patient appropriately treated with estrogen would not be counted and the practice less likely to meet its target. Therefore it is not going to be offered even if appropriate. The message that estrogen is an effective means of prevention and treatment of osteoporosis does not appear to have reached the ears of the Department of Health or the GP negotiators.

If we can start talking once again about the potential benefits of estrogen for bone then hopefully that should open the door to discuss all other aspects of postreproductive health. Cardiovascular risks, cognitive issues, emotional wellbeing, urogenital problems and sexual health are just as familiar to those interested in menopause as hot flushes. Would it not be a really good thing to ‘give women their life back’ as well as prevent osteoporosis (and possibly some coronary heart disease)? The QOF suggests that we wait for the pain and disability of fracture and only then try to prevent it happening again. Surely it would be preferable to stop it from happening both for the individual and to reduce the burden of cost to the NHS and society? Nobody has their wellbeing enhanced by the current list of bone-sparing drugs in any way other than by the promise of fracture risk reduction and many have potential adverse effects that detract from quality of life.

The inclusion of osteoporosis in QOF is to be welcomed as a means of improving secondary prevention of fracture within the UK. It is not of itself going to raise the profile of menopause care but may be an opportunity to raise awareness and counter 10 years of negative publicity. Our challenge as menopause clinicians is to push at the door that is now ajar and let ourselves back into the room.