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The return of QOF: too much, too soon?

13 April 2022

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Practice managers talk to Kathy Oxtoby about the reinstatement of QOF and what it means for general practice.

The Quality and Outcomes Framework (QOF) might be back this month – but for practices the work never went away, practices managers have told Management in Practice.

NHS England announced the resumption of the payments system last December after QOF was part-suspended in 2021/22 to free up time for Covid vaccinations.

But while the QOF system was on hold, many practices have carried on with QOF targets throughout the pandemic, continuing to measure their performance against these indicators..

Now the programme has officially returned, despite concerns that the system does not take into account the significant impact of the pandemic on long-term conditions, and could financially penalise practices. Practice managers are, once again, having to get to grips with targets, and needing to organise appointments for patients most in need of a face-to-face review, while dealing with day-to-day work pressures and staff shortages.

Here practice managers share their thoughts on the comeback of QOF, what it will mean for them and their practices, and whether its return is too much, too soon.

‘Ticking boxes around patient care is not the best use of our time’

Nicola Davies, practice manager, Roseland Surgeries, Cornwall, and chair and director of the Institute of General Practice Management (IGPM)

‘I’ve been involved with QOF since it started in 2004. Year on year the goal posts move, more criteria are added or points are moved around, and it feels bit like we “rob Peter to pay Paul”.

‘QOF is also likened to “tick box medicine”. There seems little in the way of rhyme nor reason to the movement of criteria and points allocation every year.

‘But at the very heart of QOF is the fact that it’s about good clinical practice, and proactive and preventative care.

‘However, it’s too soon for QOF to be starting up again, because we’re still trying to get things back on track. If it could be shelved for another twelve months, it would give us time to allow things to settle down.

‘Dealing with the day-to-day is hard enough with demand from patients for routine appointments going through the roof – it’s higher now than before Covid – without adding on additional work like QOF. There are only so many staff and so many hours in the day.

‘We’re back to “normal” from the first of April with QOF, as if there had never been a pandemic. Yet there are higher numbers of Covid cases within my area than this time last year. Clinical and non-clinical staff are off sick with Covid, which is impacting massively on the basic work that we can achieve.

‘QOF workload is a bit like a snowball at the top of a hill. It starts in April and as it rolls down the hill through each month it gathers more snow and becomes bigger so that by Christmas you have huge snowball at the bottom of the hill where you’re trying to play catch up. By October there will be the flu vaccines and, no doubt, Covid boosters to add to the workload. So, it’s going to become more difficult to achieve our targets.

‘During the Covid pandemic it’s been hard every day with staff off sick not just with physical illness but also stress and burnout. Practice managers arrive early, leave late, take work home, and work weekends. Some are resigning, and there are recruitment issues.

‘I would love us to get back to basics, to get back to just looking after patients without the need to reach targets. I don’t want to be chasing percentages where patients are concerned. Ticking boxes around patient care is not the best use of our time.’

‘QOF has been on the backburner, and it’s got to be done’

Mairead Roche, practice manager, Barnet, north London

‘It was absolutely the right decision to suspend QOF – how could we be expected to do it during lockdowns?

‘But the actual work didn’t really go away. We were consulting with patients, and nurses were still carrying out face-to-face work.

‘I’ve mixed feelings about QOF restarting. It’s a good thing that it’s bringing back the teamworking we used to have before Covid-19. It’s also a chance to reconnect with some of our patients, to look at preventing ill health, and to help people to make better lifestyle choices. I want patients to come back to us for face-to-face appointments. I want to have a more traditional connection. I don’t like the virtual world for everything. 

‘But the problem is: how do we get the QOF work back on track? We know that requests for consultations have increased exponentially. Resources are stretched. We don’t have enough nurse appointments. And there’s a backlog of mammograms, immunisations, and smear tests.

‘We know some targets are not going to be achievable, and if we aren’t achieving them, we’re losing money. Chronic illnesses, for example, are going to be very challenging because prior to Covid most of these patients were able to come to the practice. Now many have long Covid, their conditions may have become worse, they may be reluctant to visit us, and they will be harder to reach.

‘QOF also takes time – we need to give protected time for staff training, and to set aside time to request patients come to the surgery who we haven’t seen perhaps for a couple of years. We also need time to catch up with the care backlog.

‘I don’t think QOF is starting up again too soon though. Practices have been through a period of massive readjustment. But you just get on with it.

‘Dealing with QOF is like having a parcel that’s sitting there on the desk that you have to unwrap. It’s been on the backburner, everybody knew it would come back, and it’s got to be done. And we’ll do it.’

‘We need the whole team to help with planning how we can deliver QOF’

Jan Rimmer, head of services for the Practice Managers Association (PMA)

‘Practices never really stopped delivering QOF. But now, it will involve ensuring that registers are up to date, as there has been a fair bit of movement during the pandemic.  

‘There will also be lots of patients with many more long term conditions that will need managing due to the pandemic, which will mean ensuring that coding is correct so these patients can be identified and then receive the correct care.

‘I would hope the majority of practices – knowing that QOF was returning – had got their systems in order to allow for it to commence on the first of April. The days of practices focusing on QOF during last the last three months of the financial year are no longer. For the majority of practices, it’s a twelve-month process that they go through and evaluate throughout the year.

‘There are always changes within QOF – but it’s about having time to ensure clinical systems are up to speed with those changes. And at the moment general practice is constantly challenged with changes involving the new GP contract. So, it’s the general overburden of workload that will cause challenges in practice, and the fact that we’re two years into the pandemic and people are tired and burnt out.

‘Now is about finding the time to look at how we can work smarter and leaner in practice, rather than just taking on board everything that’s being thrown at us. Practice teams are exhausted after two years of constant changes. So we need the whole team, including ARSS (Additional Roles Reimbursement Scheme) to help with planning how we can deliver QOF safely to patients.’

‘We need to keep hold of the advances we’ve made during the last two years’

Amy Elliott, practice manager, King George & Manor House Surgeries, Stevenage, and regional representative for IGPM

‘Half of me is pleased with the return of QOF, which means a return to some sort of normality.

‘QOF is comfortable, it’s familiar, and after years of uncertainty and constant change it’s an important part of our core function – which is patient outcomes and trying to monitor long term conditions.

‘But I’m equally apprehensive as to what we’ll face towards the end of the QOF year in terms of Covid and the winter season.

‘The more the outside world goes back to some sort of normality, the more general practice is expected to do that as well. However, a lot of our staff have been off due to Covid. This means having to cancel or reschedule appointments and manage patient expectations.  

‘Our practice has maintained QOF as much as we were able to, doing long term condition reviews. Now we need to look at how we can keep hold of the advances we’ve made during the last two years, such as doing some asthma reviews remotely.

‘I’m 50:50 about whether QOF is starting up too soon again or not. We need to start it again at some point. But I worry about what will happen as we move towards the end of the year, as there’s been no mention as to a sliding scale of achievement, and whether we’re going to be compensated if we don’t meet our target numbers.

‘A concern is we might not achieve QOF targets because of the unknowns. There’s staff sickness, flu vaccinations, and we don’t know if there’s Covid vaccinations at the end of Autumn, all of which could impact on our staff levels. Winter is always a difficult time, but now there’s also that unknown factor – Covid.

‘It would have been nice to have reassurances of some kind of income protection as we come out of that last two years of the pandemic, but it seems like the band aid has been ripped off and “away you go”. We’ll be working hard to meet those targets.’

‘QOF targets for childhood immunisations are unrealistic and unachievable’

Denise Smith, practice manager, Merepark Medical Centre, Alsager, Cheshire, and SMASH PCN manager 

‘QOF never went away for us – we were able to continue with the system throughout the pandemic. The practice had a nurse shielding and she was issued with a work laptop. Patients were invited for a telephone review in their birth month – the practice has run a birth month annual recall for many years.

‘Bloods for drug monitoring restarted after the first lockdown, so patients prescribed medications for long-term conditions had their annual bloods and a follow up telephone call consultation from our practice nurses or GP.

The practice will continue to offer a mixture of face-to-face, video and telephone consultations in the patient’s birth month for their annual multimorbidity review. We will also continue to send out text invites to those patients who have agreed to this form of contact, therefore continuing with technology changes which were adopted during the pandemic.

‘The rapid adoption of technology during the pandemic has had a hugely positive impact on how we invite and manage the delivery and achievement of QOF targets. For example, Accurx provides text messaging between patients and practices, video consultations, patient information leaflets and care plans texted to patients, as are tests and appointments.

‘A concern with QOF is that childhood immunisation targets are particularly unachievable. Our advanced nurse practitioner tells us that our practice achieved 94%  of this target. We have four children out of a total population of 71 children aged one to five years who have not been immunised. One of the four children was registered at the practice in February this year, which skewed our achievement – prior to this new registration we had achieved the 95% target.

‘All other QOF targets have a three-month grace from date of registration with a practice, but there is no such recognition or exemption code for this immunisation target. And so the practice does not receive any financial reward for the children who were vaccinated, which is very frustrating.

‘QOF provides structure and targets for general practice in the absence of any other alternative. However, QOF targets for childhood immunisations are unrealistic and unachievable for the significant majority of practices.’

‘We’re adapting what we’ve been doing well

Lisa Fall, business partner, The Atrium Health Centre, Dorchester, Dorset

‘We have no real worries about QOF restarting. We never stopped it.  

‘In 2019 we started a new recall system, looking at the month patients were born, and calling them in that month to review their different conditions. This meant we could deal with everything at the same time – reducing the amount of times patients had to come the practice.

‘When the pandemic happened, we looked at which patients we really needed to see – whose health would suffer if we didn’t call them in – and which patients we could talk to over the phone to just check that they’re ok. So that’s what we’ve done over the last two years.

‘This approach has worked. When we looked at the number of patients we’ve either seen or spoken to over the phone, our figures are not really any different to 2019 when we started the new recall system.

‘Now we are just adapting what we’ve been doing well, and will be calling in more patients for face-face appointments. 

‘There are areas I’d like to change about QOF. The biggest one for us is the vaccinations and immunisations sections – I’d love for that to be removed or altered. I can see the point of having it – we should be encouraging every family to have their children immunised. But last year we had about 182 patients who needed to be vaccinated and 19 of them were not – their parents did not want them to be vaccinated. So we lost 30 QOF points, which is ridiculous. There was nothing we could have done as a practice – it’s the parent’s choice – but monetarily we were penalised.

‘Throughout the pandemic we’ve carried on working, but it’s still going to be hard catching up – we’re now trying to get patients back on secondary care waiting lists.

‘My advice to other practices about QOF is to take it in little sections. Look at those patients within those little sections that really need treatment, such as patients with diabetes who are frail and vulnerable and who need your support. Take everything in small steps. Don’t look at the whole picture – or you’ll feel swamped.’

Read more about what practice managers need to know about QOF and finance here.