Our expert panel tackles the challenges that you face. Compiled by Kaye McIntosh
Dr Gavin Jamie is an expert on QOF and a GP at the Whalebridge Practice in Swindon, Wiltshire; Kay Keane is PM at Alvanley Family Practice, Stockport, Greater Manchester; Michelle Barksby is PM at Sherwood Medical Partnership, Mansfield, Nottinghamshire.
Dr Gavin Jamie, an expert on QOF and a GP in Swindon
Despite the suspension of many the QOF indicators this year, more than 45% of the points remain in play. Like the final round of a TV game show, we have double points for flu vaccination and cervical cytology. Practices are already ahead in their flu programme and cytology achievement is mainly based on testing from before the pandemic.
Indicators about prescribing remain. These cover ACE inhibitors and beta blockers in heart failure due to left ventricular systolic dysfunction and statins in patients with diabetes. Aspirin for patients with CHD or stroke and anticoagulation in atrial fibrillation are also included.
Annual reviews for these patients can take place either in person or remotely, although some monitoring of blood tests will be required. Despite the disruption of care this year, the need for review the treatment of patients with chronic disease is probably more important than ever.
The Quality Improvement (QI) indicators also continue, this year covering cancer and learning disabilities. The requirements have been simplified and are now mostly about delivering as normal a range of services as possible. These requirements will, as always, be much simpler if you start earlier – look at the reporting templates now.
The final indicators still in play are some of the simplest but have the biggest effect on practice income. Disease prevalence determines the value of all clinical points. In normal years most practices achieve well over 90% of the total points, but there are large differences in the associated payments due to variations in prevalence. Making sure that patients are correctly diagnosed and coded can have a much bigger effect than gaining or losing a few points.
Some conditions will be diagnosed after an acute presentation. Coronary heart disease and stroke, for example, will normally be diagnosed after a patient presents to the surgery or the hospital.
Other areas will require some investigation by the practice. With potentially fewer contacts this year, we need to make sure that each one counts. Have a system to identify patients who are at risk of diabetes – either a previously high HbA1c level or possibly a raised QDiabetes score – and make sure that an HbA1c is included if blood tests are required for any reason.
Patients having a blood pressure measurement can easily be checked for an irregular pulse. A clear pathway to ECG and diagnosis will ensure that patients can be quickly added to the register and treated.
The obesity register is normally worth about £2 for each patient with a BMI of over 30. It is likely that fewer patients will be weighed in practices this year, so the value could be higher. Consider asking patients to monitor their weight at home and report back to the practice. This could be by phone, but text message, email or other remote solutions can be effective.
Respiratory testing is also restricted this year, so asthma and COPD diagnoses will be on clinical grounds. Individual peak flow meters can be prescribed and a code for ‘spirometry not available’ should be used.
● Review prescribing at annual reviews.
● Check high risk patients for diabetes – a one-stop shop will reduce visits to the practice.
● All clinical staff should be aware of how to investigate an irregular pulse.
● Patients can monitor their weight at home.
● Respiratory disease can be diagnosed with history and examination only.
● Don’t forget your QI submissions!
Kay Keane is PM at Alvanley Family Practice, Stockport
Whatever we might think about bean counting, I would rather try and use it to our advantage, to make sure all our patients get the best care possible. Over the past four years we have managed to obtain 100% of the points, thanks to commitment from the whole practice and ownership by one of our nursing team. Gaynor, our HCA, has just completed her AP qualification.
Find the best person in your team for the job, who really wants to ensure improvements are made, and doesn’t mind being a nag to those who miss pop-ups and reminders when they see patients. Gaynor does that with fun and passion. I couldn’t ask for better support. You’ll have your own Gaynor in your team: empower them and let them do what they are good at.
This year we have PCN points, so look within your team (and the PCN) to address or lead this work. The real skill of a PM is attracting, empowering, and engaging the people around them. Find that foundation doctor, nurse associate or skilled administrator that can lead on a project across practice boundaries. How amazing would that look on their CV? Provide them with the time, direct them to the knowledge base, and offer them regular short meetings to keep track of their progress. This will do more to enhance your team than you working 80 hours a week to get it done.
The new cancer target (QIECD006) specifies: ‘The contractor has participated in network activity to regularly share and discuss learning from quality improvement activity focused on early cancer diagnosis as specified in the QOF guidance. This would usually include participating in a minimum of two peer review meetings.’ It is crying out to be led by your wellbeing or care navigation teams. We started to have a ‘CommuniTea’ cancer group before lockdown – people touched by cancer could meet informally and discuss their (or their family member’s) treatment, sharing their stories and experience to build a strong support network outside the practice.
We are also delivering a Facebook Live event on breast cancer. We know that when patients hear from people like them, they listen and take notice far more than they do when a healthcare professional tells them. Anna will discuss her breast cancer diagnosis, how she broke the news to her young children, and what treatment she had. When she tells our community what it really feels like finding a breast lump, I know they will listen.
Not all targets are met in an office. We are moving to a time where we can be more creative, we can share skills and look within our practice and patient community to support us more than ever.
Michelle Barksby is PM at Sherwood Medical Partnership, Mansfield
This was going to be a big year of change for QOF. The recycling of 97 points and changes to established indicators, as well as 11 new, was intended to revitalise QOF with a more clinical, evidence based focus.
But we’ve all been forced to focus elsewhere in 2020. So, how to tackle a new set of indicators in a global pandemic, when practices are faced with an uncertain winter in which we have to deliver the largest ever flu campaign – and may be asked to step in to deliver Covid vaccination and possibly even Covid testing?
The approach will always depend on your practice size and patient demographic, but some indicators were always going to be more challenging in the current climate than would usually be the case. Newly adjusted asthma indicators requiring confirmation of a diagnosis with two diagnostic tests, when taking into account the required changes for spirometry accreditation of staff, would have been challenging in any year. Doing so currently under Covid would be near impossible with spirometry being classed as an aerosol-generating procedure.
As such NHS England/Improvement have agreed relaxations to QOF requirements under Covid for the 2020/21 year. These include protecting practice income in 310 QOF indicator points to allow flexibility for elements of care which would be inappropriate, impractical or impossible during current Covid restrictions. While aiming to undertake work towards these indicators where possible and practical to do so – treating patients holistically when they are in contact with the practice – practices have some flexibility to not focus on these areas.
Vitally, some areas of QOF still require practice attention. Flu vaccinations and screening thresholds should be an important focus for practices and aligns with the wider national agenda. Vaccinating as many eligible patient patients against flu as possible will protect your patient population but also, as the QOF points around flu have been weighted towards the lower thresholds, practices will benefit from this through increased QOF revenue too. Screening indicators mirror this pattern also with higher weighting of points towards lower thresholds. Active promotion of screening provides effective ways of identifying cancers early, while also ensuring practice income is stable to deliver the screening opportunities for patients to attend.
Maintaining disease registers is important this year with 81 indicators assigned to this area and with established registers in most indicator areas already in place this should be an area of QOF which should require less focus to maintain. Improving practice prevalence and checking register accuracy are areas which could help in boosting practice income in this group of indicators where practices have the time and resources to do so. Indicators related to prescribing will be key, as they will still be determined on performance and would likely be an area for practices to focus their attention early.
The main focus for new work in QOF this year will need to be around the quality improvement areas. Again, the requirements around these indicators have been softened due to Covid but peer working with your PCN is essential to achieve these areas in learning disability services and early cancer diagnosis. As indicated earlier active promotion of screening will also help with this.
For further information on the changes to QOF under Covid, visit Pulse Intelligence.