A Path to Better Health Outcomes: Kenya Introductory HTA Technical Workshop
Is QOF a magic bullet?: Key take-aways from Quality Outcomes Framework workshop
ต้องการข้อมูลเพิ่มเติม ติดต่อฝ่ายสื่อสารองค์กร HITAP
By Chayapat Rachatan and Kanchanok Sirison
On June 28, 2022, the Health Technology and Assessment Program (HITAP), Ministry of Public Health, Thailand, hosted a workshop on “Health incentive mechanisms present and future: UK’s experience of Pay for Performance and Quality Outcomes Framework (QOF)”. It was a closed consultation meeting, attended by officers from the National Health Security Office (NHSO), experts and researchers working on the QOF.
Dr. Lalittaya Kongkam, Deputy Secretary General, NHSO, moderated the discussion and opened the workshop. She welcomed Dr. Phusit Prakongsai, an advisor from the Health Technical Office, Ministry of Public Health, Thailand, as the chair of this workshop. The keynote speakers were Prof. Paramjit Gill, Head of the Division of Health Sciences, University of Warwick; Mr. Kanit Sangsuwan, Deputy District Director, NHSO Health District 2; and Ms. Kanchanok Sirison, Project Associate, HITAP. The speakers shared experiences on the implementation of the QOF programme in the UK and Thailand, as well as the researcher’s perspective on conducting research related to the QOF followed by an open discussion with questions from those in attendance.
History of QOF in the United Kingdom
QOF was introduced by the British General Practitioners (GP) as a mechanism of using financial rewards to improve quality of care for entire populations through the management of individual patients. The payment mechanism was designed to link the incentives and quality targets for managing common diseases such as asthma and diabetes; implementing preventive measures such as blood pressure checks; and targeting hard-to-reach population groups, especially the elderly, children, and minority ethnic populations, as well as at-risk groups who receive vaccination or are included in screening programmes.
The secret to the success of QOF in the UK was that there were many indicators embedded in routine clinical practice and were used to measure the process. When the patient comes in, all QOF indicators will be listed, and clinicians can follow the indicators during the consultation, which leads to the integration of care among health professionals. This approach has improved clinical practice, driving up quality and helping deliver consistent care.
However, in England, health services, such as GP practices and hospitals, are being run by different organisations. The country, therefore, established the Integrated Care System (ICS) on July 1, 2022. This was thought to bring together the services that both the National Health Service (NHS), social services and local authorities are working cohesively under this system. Like any other interventions, ICS is still at an early stage of development and England is currently exploring its outcomes.
How can Thailand learn from UK’s experience?
Thailand followed in the footsteps of the NHS and the NHSO implemented a QOF programme in 2014. HITAP was one of the research teams tasked by NHSO to study the implementation of QOF and the development of quality indicators for primary care under the Universal Coverage Scheme (UCS) in Thailand. The study, conducted in 2015, reviewed the QOF programme and recommended a new set of quality indicators. The research findings suggested that strong collaboration between NHSO and MOPH in developing the QOF policy and implementation as well as having the basic infrastructure would lead to improving primary care services.
NHSO started to apply a quality-of-service criteria for payment, first called as Pay-for-Performance (P4P), in 2007 and the name was changed to ‘Quality and Outcomes Framework (QOF)’ in 2014–2019. The budget received varied from year-to-year and was proportional to the Outpatient (OP), Inpatient (IP), and Health Promotion and Disease Prevention (P&P) budget.
During the two decades of implementing the UCS, Thailand also adopted various types of payment mechanisms for healthcare providers, one of which was the QOF mechanism to improve the quality of services. Implementing QOF was not without its challenges which related to linking to policy, assessing the impact of the QOF on the quality of care, the value for payment, and the unavailability of the health information systems for some quality indicators.
Challenges in the implementation of QOF programme
To monitor the impact of QOF, HITAP, together with the University of Warwick, conducted a study during the pandemic, titled ‘The study of policy dialogue on the impact of the Quality Outcomes Framework (QOF) in Thailand’. This study aimed to understand the QOF indicators on utilisation of health services for diabetes as a case study and used big data analytics. Based on the e-claims database from NHSO, the study identified a spike in OPD services for diabetic patients with complicated conditions during the first wave of COVID-19 pandemic (early 2020) in Thailand.
However, it is not easy to demonstrate the impact of the QOF programme directly. Owing to the constant change of QOF budget policy and a lack of monitoring system for implementing the QOF programme, the budget allocated to the QOF programme reduced significantly. It is possible that some quality indicators were repeatedly selected by the health regional committee based on the performance of health facilities to secure the budget rather than to target the quality-of-service issues. Additionally, researchers found it difficult to conduct the study as access to the de-identified data on account of the provisions of the recently enforced Personal Data Protection Act (PDPA); further, the quality of the data received from the programme was wanting.
Although the budget for QOF programme in Thailand was discontinued by policymakers, this study highlights the importance of the need for having better financial schemes for quality services. To avoid budget allocation being wholly dependent on priorities of the leadership, programmes must be able to show stakeholder involvement, have measurable impact with measurable indicators that are based on justified evidence, and have transparency in payment. Interestingly, it was found that QOF budget indeed motivates the improvement of service quality at the beginning of the programme, however, it must be followed by setting in place the regional implementation framework to closely monitor the programme and actively encourage the participation of healthcare networks which can affect the development of quality service.
What is the way forward?
Without a doubt, a robust monitoring process is required to enhance the quality health outcomes. It is unclear whether Thailand will decide to adopt any new pay-for-performance scheme to improve the quality of primary care services. Like in the UK, Thailand has separate entities working on different budget portions to improve the quality of the primary care services. Learning from the experience of the QOF programme, it may be time for Thailand to integrate the services for care and health financing schemes for the whole system.
Overall, in addition to having a rich database, a strong collaboration and cooperation from all relevant stakeholders, including patients, providers, payers, and government, will be critical for having successful financial mechanisms and improving quality of services.
Acknowledgement
The authors would like to thank Chittawan Poonsiri and Saudamini Dabak for their inputs on this blog. The workshop was part of a project titled “Policy dialogue on the impact of the Quality Outcomes Framework (QOF) in Thailand”, funded by the Policy Support Fund, University of Warwick. The findings, interpretations and conclusions expressed in this blog do not necessarily reflect the views of the funding or participating agencies.
12 May 2023
