ast year in Scotland, the average number of quality and outcomes framework (QOF) points for a practice with a standard general medical services (GMS) contract was 980.09, with a corresponding average QOF payment of £138,932.
Approximately 88% of Scottish practices have a GMS contract. While not every practice chooses to participate in QOF – either for their own in-house reasons or because they have signed up to a different contractual arrangement, ie, a section 17c or 2c contract – 99% of Scotland’s practices submit some level of QOF data.1
The QOF challenge
For those practices that do participate in QOF and are already achieving full, or near full, points, it is without doubt getting more and more difficult to squeeze additional or new income from QOF. Do you remember when we all went around saying ‘points make prizes’? Well, unfortunately, times have changed and there are definitely not as many of those prizes to be had anymore. As one of my Edinburgh practice manager colleagues recently observed, “any new money is only to be found in the enhanced services”. Nonetheless, for most of us, achieving QOF points is still part of our day job, so whether we like it or not, we just have to get on with it.
Achieving those points may no longer mean prizes but it does still mean work. Work and challenges that we rise up to meet year-on-year are reflected in the statistic that in 29 out of a possible 31 indicators, Scottish GMS practices obtained an overall achievement rate above 95%. The highest performance in the year 2011-12 was seen in the hypothyroidism indicator, and the lowest achievement was in the learning difficulties indicator – possibly due to the well-rehearsed issues around identifying and coding patients with such a diagnosis.
As you will be well aware, the NICE recommendations for QOF 2012/13 included:
- Eight replacement indicators focussing on mental health, asthma, diabetes, atrial fibrillation, depression and smoking.
- Nine new clinical indicators, two of which are new clinical areas, ie, peripheral arterial disease and osteoporosis.
- Three new organisational indicators in quality and productivity (QP) looking at A&E attendances (replacing the prescribing element).
- The usual round of tweaking ceiling and floor thresholds, notably raising the minimum percentage for all indicators from 40-90% to 50-90%, and bringing up the lower threshold to 45% for all upper thresholds in the 70-85% range.
Not surprisingly, the statisticians can give evidence that practice achievement is (generally) lowest where the indicators have been newly introduced, but this improves steadily each year as the indicator becomes established. What this does not highlight is the amount of work it takes the primary healthcare team to reach that pinnacle of achievement – maximum points. You do not need me to describe the rounds of new searches, identifying new patients to include or those that should be exempt, trawling through computer records and notes (don’t you just hate Lloyd George envelopes?) Perhaps this is a good moment to stop and record our thanks to those clever people who came up with BlueBay, or whatever other invaluable pieces of contract software you favour. We all realise the need to keep upping our game, to improve the quality of the services we offer – after all, the clue is clearly there in the name of the framework. However, even achieving full marks does not quite remove that gnawing feeling in the back of your mind that you are doing an awful lot of work for re-cycled points and little new money, flying in the face of what the new GMS contract was supposed to have been about – ie, no new work without new money.
A team affair
So how do we sustain current levels of QOF achievement? Or indeed improve on these? As ever, this will come down to the efforts of the practice team. It is, of course, our job to make sure that everyone in the team knows what is required of them, when and how to record this activity, result or outcome – with the correct code – on the computer. This may require a little bit of nagging – usually aimed at the GPs rather than the practice nurses, from my experience! (I have often wondered why this skill is never cited as a key management competence – as far as I am concerned, this is an absolutely essential attribute for every practice manager).
Do not forget to involve the administrative and clerical staff in the quest for QOF points. You would be amazed how often administrative staff turn up to one of my training sessions with absolutely no idea about QOF – or anything else to do with thw new GMS for that matter. They may be doing the related work, eg, calling people in for review appointments, inputting data and so on, but have no understanding of why or how this fits together. How can anyone derive job satisfaction from just carrying out tasks without any context? Can you imagine being given a job to do but not knowing why? Think how much more engaged the staff would be if they realised that they have an important role to play in helping the practice to achieve its goals, not to mention that this is in part how we earn income which is used to pay the salary bill each month.
I acknowledge that engendering renewed enthusiasm in the team to not only maintain current efforts, but also to meet those new targets and thresholds mentioned earlier, is testing. The days of rewarding staff for high QOF points are long gone, so other creative ways need to be found. Only you will know what suits your practice best – but incentives could range from a practice night out, to time in lieu for extra work, to providing biscuits to go with the tea and coffee. I have no hesitation in recommending you do whatever it takes (provided it is legal, of course)!Given that I am advocating a joined-up approach – and that I am always on the lookout for shortcuts – it struck me that the best way to answer my question about sustainability was to ask the experts. So, on your behalf, I canvassed a group of local practice managers, asking them for their top five QOF tips in order for me to present them together for the benefit of all. So here they are – and timely too given that as we leave 2012 behind, we are entering into the least favourite quarter of the practice manager’s year:
1. Never think that QOF can be achieved in only a month. Practices should be working towards QOF all year round. A planned approach with effort spread across the year is much more effective – and efficient. Unfortunately there are a number of practices that never seem to learn this lesson from one year to the next. Hopefully this is not you!
2. Use clear and simple indicator-identifying and recording software packages. Make sure that everyone knows how to use these and that they are working in consistent and agreed ways.
3. Invest time in verifying disease registers. Should all patients still be there? Is the diagnosis correct/still relevant? This is absolutely vital work if you are to have complete, robust datasets on which to base your recalls and subsequent consultations and tests.
4. Ensure the team makes use of all available resources, such as IT. And equally importantly, make use of one another. In one practice, smoking cessation is as much a part of the admin team’s remit as it is the clinicians, with the staff routinely sending letters and information about quitting smoking to targeted patients.
5. Name and shame. This has to be my favourite tip. The practice manager responsible for this piece of advice regularly publishes league tables stating exactly how many (or few) QOF points each GP or nurse has obtained in their designated clinical indicators. She tells me that her ‘scores on the door’ approach brings out the competitive streak in everyone and that the improvement in performance is “jaw-droppingly good”.
With grateful thanks to everyone who contributed to this list of tips. I hope that there is something here for everyone. Wishing you all a QOF-prosperous New Year.
Anne Crandles is a freelance practice management consultant in Edinburgh. She is a local co-ordinator for the Scottish Practice Management Development Network.
Information Services Division, NHS National Services. Quality and Outcomes Framework (QOF) of the new GMS Contract – Achievement, Prevalence and Exception Reporting Data 2011/12. Available at: www.isdscotland.org.
British Medical Association. Quality and Outcomes Framework for 2012/12 – Guidance for PCOs and Practices. Available at: www.bma.org.uk.