GP Gavin Jamie summarises important changes to QOF for this year and the indicators practices need to pay close attention to urgently, if they are to avoid missing out on income.
The Quality and Outcomes Framework (QOF) is back in full swing for 2022/23. We did say the same last year but, in a time of greater optimism, it seems less likely that there will be significant disruption this year.
That is not to say that practices haven’t been active delivering routine care over the last couple of years. There is plenty of evidence to show that chronic disease monitoring and treatment has continued all through the pandemic.
However, the return of the QOF this year means that being aware of and complying with all the rules again becomes important for maintaining practice income. So, what are the important areas to highlight?
Be alert to those indicators that have deadlines
Most indicators have been based on data from the end of the QOF year. It is normally possible to work through the year and then have a ‘tidy up’ right at the end.
Recently though, an increasing number of indicators have a deadline that may fall before the year end and so need attention earlier in the year. If that deadline is missed, there is no way to go back and ‘fix’ it.
Two areas that require action within six months of diagnosis are asthma (AST006) and heart failure (HF005). For the former, there should be confirmatory spirometry and one other objective test in that timescale. For heart failure, this should involve an echocardiogram, or at a minimum, a referral for one. Crucially, these apply to all patients who were diagnosed after the 1st of April 2021. This means that, although these indicators were nominally suspended last year, your achievement during 2021-22 will still count towards this and subsequent year’s QOF.
Look at these areas urgently to see if you have patients diagnosed within the last six months without coded investigations – these would have been easy to miss at the time.
That six month clock restarts if a patient registers at a new practice. The investigations don’t need to be repeated but if they haven’t been coded in the past, then they should take place within six months of registration at the new practice.
If the six month window has passed there is no way to achieve these indicators and this will affect achievement for subsequent years. It would be prudent to go back and check that investigations carried out in the past year were correctly coded. Personalised care adjustment (exception reporting) is available if an investigation was not available, not clinically appropriate, or declined by the patient.
There are similar time sensitive indicators for follow up after a diagnosis of depression or cancer, and another for referral to a diabetes education programme. The diagnosis may have occurred during the 2021-22 ‘protected’ QOF year, which means the deadline for follow up of individual patients may be approaching. The actual timescales vary from 56 days for a depression review to three and 12 months for the cancer review. Diabetes education referral should be within nine months of the date of diagnosis.
Don’t be misled by the wording used for these indicators suggesting that only patients who are diagnosed in the current QOF year are included. This is not accurate – it is the date of the review or referral deadline that needs to be in the current QOF year, instead. On a slightly brighter note, any failure to achieve these indicators will only affect one year rather than every subsequent year, as happens with investigation indicators discussed above.
Carrying out an urgent review of all these time sensitive indicators at the start of the QOF year could save a lot of stress later down the line. All patients with new diagnoses in these areas should also be followed closely throughout the year to make sure that deadlines do not pass without the appropriate investigations or reviews taking place. Just monitoring your projected points score may not highlight problems until too late.
Take action on physical health checks for patients with mental health problems
There are no new indicators in QOF for this year and no significant changes to the existing ones. There have, however, been appreciable changes over the last couple of years that have never been fully implemented.
Last year saw the introduction of new indicators around physical health checks for patients who are on the mental health register. Although they were suspended before the end of the 2021/22 year, these indicators are still in place this year. Patients on the register will need a measurement of their body mass index and blood pressure, as well as a record of alcohol consumption and blood tests for cholesterol and glucose or HbA1c. Make sure this is on your chronic disease recall checklist.
Although patients can’t come off the mental health register they can be marked as being in remission if they haven’t required medication or specialist input for five years. Checking this early in the year will help ensure your practice calls in the correct people for a physical and mental health review.
Updated Quality Improvement indicators
The Quality Improvement (QI) indicators have not had the best of starts over the last couple of years. These have been updated for 2022/23 and now cover prescription drug dependency and optimising access to general practice. There are 37 points for each area, worth over £7,500 to an average-sized practice.
There is detailed guidance and suggested actions in the QOF documentation. For prescription drug dependency, the priorities are around the prescribing of opiates, gabapentinoids, benzodiazepines and Z-drugs – particularly when they are used over long periods. There should be a baseline audit of prescribing and drug monitoring, followed by a review of the audit results in a meeting with the rest of your PCN, and then an action plan. After implementation of the action plan there should then be a further PCN meeting which, the guidance says, should be focused on ‘celebrating success’, although do remember that this is a business meeting!
By far the simplest approach to creating your aims and action plan is to copy and paste the examples from the guidance with adjustments as needed based on the results of your baseline audit. You are welcome to create your own action plan and targets but this will involve additional work. There are no extra marks for originality.
At the end of the year there is a standard reporting template to be sent to the commissioner with specified font and size. In previous years this was one page long, it has now expanded to two.
The second QI area, optimising access to primary care, has the same general structure. In this case most of the suggestions are around monitoring demand for appointments and how efficiently the appointments are used. The monitoring and auditing can be done by non-clinical staff although patient facing staff should be involved in plans to remodel services.
There is copious guidance available although the London General Practice Access Guide is suggested as a good source of information.
Nothing in the guides is likely to be new to most practices and it is not expected that there will be measurable outcomes at individual practice level. What is important for this indicator is that the process is followed: carrying out an initial audit, holding a meeting across the PCN, the setting of achievable goals and finally a further PCN meeting and possible celebration. There is a form which will need to be submitted at the end of the year in order to claim the points.
Childhood vaccination targets and effect on income
While childhood vaccination indicators moved into QOF at the start of 2021/22, the effect on income of this only became more apparent to practices towards the end of that QOF year. While these are tough indicators with high thresholds for payment and that aren’t covered by exception reporting, there are a few things to bear in mind.
Remember that every vaccination is paid at the standard item of service (IoS) rate, £10.06. The QOF thresholds can make it seem as if you don’t get paid at all until you reach the 90% target in some areas but this is not the case. Every vaccination is clinically and financially worthwhile.
Secondly, compare your payment now with your previous payments, not the potential full points. It is likely that most practices won’t attain all of the points available but many will still be financially better off than they were under the previous system prior to 2021, taking into account both thresholds and IoS payments. For example, in the past practices will only have been paid for infant diphtheria, tetanus and polio at certain thresholds. Now each immunisation attracts an IoS payment as well as possible QOF points. Even without full points this could pay more than under the old system.
If practices do gain full points this will represent a big cash increase compared with past payments.
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website
See the full guidance on the Update on Quality Framework changes for 2022/23 here.
This article was first published on our sister title Pulse Intelligence. To find out how Pulse Intelligence can help your practice maximise income and be more efficient sign up for a free trial at www.pulse-intelligence.co.uk