A practice in Slough changed its approach to annual QOF reviews by prioritising high-risk and complex patients. The new model has optimised practice resources, boosted staff resilience and improved patient care. Dr Priya Kumar explains more.
At Kumar Medical Centre (KMC), our mission has always been to improve patient care and ensure it’s tailored to meet the needs of our diverse community. Serving one of the most deprived areas, where 96% of our registered population comes from global majority communities, we face significant health challenges daily.
For example, our diabetes prevalence is approximately 10% – nearly double the system’s average. These challenges demand a healthcare model that adapts to the unique needs of our population and addresses the health inequalities that often arise from traditional care systems.
In response to these challenges, KMC has aligned with NHS England’s 2025/26 planning guidance, which calls for a more personalised, proactive, and equitable healthcare system that reduces health disparities. A key component is improving the management of long-term conditions, which we focus on through tools like the Quality and Outcomes Framework (QOF).
Traditionally, QOF reviews are scheduled based on birth months, helping to evenly distribute workload throughout the year. However, this approach doesn’t account for the complexity of individual patients. Some require more attention due to multiple health conditions, while others, especially those at higher risk, may not receive the care they need in time.
Aims
Recognising this inefficiency, we knew a change was necessary. This was the perfect opportunity to rethink how we manage QOF reviews and align them with broader goals of personalised and proactive care across the system.
In collaboration with the Johns Hopkins Patient Need Groups (PNGs) and Frimley ICB, we identified an opportunity to enhance QOF reviews by categorising patients based on their health and social needs.
Using a population health approach, PNGs divide patients into 11 groups, ranging from low complexity (PNG 1) to high complexity (PNG 11) – see table below. This new system allows us to prioritise patients who need the most attention, ensuring they receive the right care at the right time, while also optimising resources across the practice.
Method
In April 2023, we began piloting this new approach, shifting from scheduling reviews based on birth months to categorising patients using PNGs.
The change allowed us to prioritise high-risk patients, match them with the most appropriate healthcare professional, and decide whether they should be seen in person or through digital appointments. Having this flexibility ensured that care was tailored to each patient’s needs, with a focus on timeliness and efficiency.
It also empowered patients to take ownership of their health. By making PNGs a part of the conversation, we help our patients understand their health needs and actively engage in managing their conditions.
This shift from a reactive to a proactive healthcare model is essential in addressing health inequalities and moving toward a truly integrated, patient-centred health system.
Outcomes
Once we introduced the new model, the results were immediate and impactful.
By September 2023, we had completed 90% of our QOF reviews, a significant improvement from 62% completion rate achieved in the same period in 2022. Even more impressive, 70% of our patients had their conditions under control by October 2023.
This early completion allowed us to focus on other essential services such as vaccinations, NHS health checks and cancer screenings. It also created additional capacity to handle winter pressures – a critical aspect of primary care management that has a potential impact on the wider system if achieved at scale.
As we moved into 2024, the improvements continued. By September 2024, we had completed 87% of our QOF reviews, with 76% of patients under control across all conditions.
KMC has also observed a 10% improvement in HbA1c control over the two-year period (population size of 482 diabetics), as well as a reduction in admissions and total bed days compared to the system average.
This highlights the potential effectiveness of our tailored approach if achieved at scale across primary care. The new model has enhanced the efficiency of our QOF reviews and improved the overall capacity of KMC, making us more aligned with NHS goals for service delivery and improved patient outcomes.
Benefits
Perhaps most importantly, the new approach has helped us reach patients who are often disconnected from traditional healthcare pathways. Through outreach programmes, such as multigenerational family support and home visits, we’ve been able to provide care for those who might otherwise fall through the cracks.
This flexibility and inclusivity are in direct alignment with the NHS’s Core20PLUS5 initiative, which focuses on ensuring access to care for underserved populations and reducing health disparities.
Incorporating PNGs into our urgent care triage process has been another transformative step. By integrating PNGs into triaging, we’ve been able to make more appropriate referrals to services like Pharmacy First. This has also enhanced continuity of care within the practice, empowering non-clinical staff with quick access to a patient’s health background, allowing them to make more informed decisions.
The most rewarding part of this transformation has been witnessing our team embrace these changes.
By shifting the focus to complexity, we’ve simultaneously improved patient care and enhanced staff resilience. Our team now has more time to focus on high-priority patients, leading to better outcomes, greater efficiency, and higher patient satisfaction.
Future potential
The potential of the PNG system is enormous. The initiative could be scaled across a PCN, potentially aligning the ARRS workforce to the population and, where appropriate, further enhancing the use of digital services. It could result in greater productivity and efficiency across the PCN footprint with better outcomes for the population.
And the potential of the PNG system extends beyond primary care. By embedding PNGs into different parts of the healthcare system, we can improve triage at A&E, NHS111, and ambulance services, reducing unnecessary outpatient referrals, and supporting elective recovery. A broader integration will help create a more coordinated and responsive healthcare system, reducing pressure on both hospitals and primary care, while delivering more efficient care.
Ultimately, our approach is more than simply improving QOF reviews or managing urgent care more effectively. It’s about creating a healthcare environment that prioritises patients’ needs, empowering patients to manage their own health, and providing care in a way that’s efficient, effective, and equitable for all.
Dr Priya Kumar BEM is GP partner and population health management and health inequalities lead at Kumar Medical Centre, and clinical advisor for primary care research at NHS England
A version of this article was first published by our sister title Pulse PCN
