For some practices, the structure of QOF targets has resulted in a dramatic drop in income from childhood vaccinations. Such immunisation programmes may now become unviable in some areas, says GP Dr Gavin Jamie
It has been nearly a year and a couple of health secretaries since the Omicron variant of Covid appeared. As case numbers rose there was a drive to get as many vaccine boosters administered as possible. The campaign started at the end of 2021 and was followed by a work from home directive at the start of 2022. To help GPs with this extra workload, much of QOF work was suspended from November 2021; this was the third year in a row where payment for most of the indicators would be based on increasingly historical data.
Payment continued or was increased for indicators around prescribing, and disease prevalence continued to determine the payment for each point. The new set of indicators for vaccinations and immunisations also continued to be paid.
The lack of payment for some indicators did not mean that the data was not collected and it has now been published by NHS England.
So, what does it reveal?
Vaccination and immunisation proved to be a very difficult area
The biggest changes to QOF in 2021-22 were arrangements around vaccinations and immunisation with a new indicator group for this introduced. Previously there had been several different schemes for the administration of childhood vaccinations and these were replaced with a combination of item of service (IoS) payments and QOF indicators. The range of achievement for which QOF points were awarded was very limited and the number of points was high meaning that quite small changes in vaccination take up caused large variations in payments. They also differ from other QOF indicators because a chunk of points is awarded in one go for getting over the lower threshold. Only 8.1% of practices achieved a maximum score of 64 points.
DTP vaccine administration saw a third of practices achieving full points and third getting none at all
The first indicator (VI001) concerned infants who had three doses of DTP before eight months. Points were awarded on a sliding scale between 90% and 95% achievement of vaccination in the cohort.
There was a pretty even three way split here with around a third of practices getting the full 18 points, a third getting none (<90% achievement) and the rest getting some of the points. Overall, a typical (median) practice had an achievement of 92.8%, which translates to about 11.5 points.
Do remember that there is an IoS payment for these vaccinations as well so even practices with no points will have been paid a little over £30 per patient.
Even this is not guaranteed, however. If achievement drops below 80% then the IoS payments may be reduced by the equivalent of 50% of the cohort. See General Medical Services Statement of Financial Entitlements Directions 2021 (Part 5, 18 (7)
So, if achievement was 79% then a practice would receive IoS payments for only 29% of the eligible children. Vaccination coverage fell below this threshold for 525 practices (8.1%). A total of 54 practices had coverage of less than 50% suggesting zero, or even negative payments. For example, this might be the case for a practice that achieves 40% of vaccinations but then has no IoS payments for 50% of the eligible cohort.
Just under half of practices were awarded no points for MMR between 12 and 18 months
It is a similar pattern for the second indicator for patients having an MMR between 12 and 18 months (VI002), with payment thresholds at the same levels as VI001. Typical achievement was a bit lower here at 91.1% but the steep points gradient means that this is equivalent to achieving 9.4 points.
The spread of practices is also much wider here. A total of 44% of practices received no points at all for this indicator and only a quarter were awarded the full 18 points. Over 1,000 practices fell below the 80% threshold although the number of practices with very low achievement (below 50%) was about the same as VI001.
Just under a third of practices fell below the 80% threshold for giving two doses of MMR between one and five years – potentially taking an income hit that makes the programme financially unfeasible
The figures for VI003 – children having two doses of MMR between the ages of one and five years – are more concerning. The achievement by a typical practice was 88%, barely above the lower threshold of 87%. This represents 8.5 points typically, although 46% of practices got no points at all and 29% fell below the 80% threshold. Only 16% of practices attained the full 18 points in this area.
There are 360 practices with very low achievement in this indicator, which may represent local problems or arrangements. The overall vaccination coverage of this age group in QOF is – at 81% – quite a bit less than the 86% as shown by NHS Digital figures, suggesting some data is missing from practice records.
Practices that have fallen below the 80% threshold are at significant risk of a financial hit that may make their childhood vaccination programme unviable.
Achievement in these three indicators is not independent. A practice with a population that is difficult to reach is likely to face challenges in several of these indicators. If childhood immunisation becomes financially unviable it is likely to have a direct effect on children.
If you are in a practice with unexpected very low achievement in VI003, I suggest reviewing the coding of children’s MMR vaccinations as a matter of urgency. Remember that both doses need to be coded on the record, even if the child changed practices between their first and second dose.
Most practices received full points for shingles vaccination
There is substantially better news for the fourth vaccination indicator (VI004). This rewards the number of patients that have had a shingles (zoster) vaccination on reaching their 80th birthday. As they may have had the vaccination just after their 70th birthday this can be rewarding work which was done a very long time ago. The thresholds in this indicator are more relaxed, between 50 and 60%. Most practices (67%) received full points for this and only 22% got no points.
For some, there is work to do here but a strategy of getting in touch with your 79 year-olds to offer them another chance to have the shingles vaccination is likely to be worthwhile.
For other QOF activity, its more business as usual
For the rest of QOF work, it was a case of things starting to get back to normal. The largest rise in prevalence was for obesity although this perhaps indicates a return to typical levels after a year when fewer patients were being weighed in the surgery.
Long-term trends continue as before with a steady fall in the rate of coronary heart disease. This represents a real achievement for general practice and public health over the last decade.
The number of patients with a diagnosis of diabetes continues to rise steadily with 7.3% of the population over 17 years old now having a diabetes diagnosis. Non-diabetic hyperglycaemia (NDH) has been measured under QOF, although without payment, over the last couple of years and the number has risen this year to 6.1% of the adult population. Together this means that nearly one in seven adults have raised blood sugar of some type.
If this trend continues, practices should be aiming for a NDH register roughly the same size as their diabetes register this year.
Everyone on the register should have an HbA1c test annually. The published figures show that achievement here is at 76%, some way below the QOF points upper threshold of 90%. This should be an area for practices to concentrate on during the rest of this year. There are 18 points available and many of these patients will be having checks for other long-term conditions.
Heart failure shows some increase in the number of patients diagnosed with left ventricular systolic dysfunction. That diagnosis is important to make sure that they are monitored on appropriate treatment but can also be financially attractive to practices due to the prevalence calculation.
It is not surprising that the indicators that were still active had high rates of achievement. For most of the other indicators, achievement is rising and returning to pre-pandemic levels. This is not particularly surprising as it was around eight months into the QOF year that the suspension of activity was announced. Achievement in many of the suspended indicators appears reduced although this is mostly a side effect of reduced exception reporting.
There is much to congratulate practices on given the published QOF figures. They illustrate a continued high standard of care amid some very difficult circumstances. Assuming that the rest of this year passes without incident it will be important for practices to engage with some of the newer indicators that have appeared over the last two years but which haven’t have yet had a full year of implementation. These include mental health indicators requiring the measurement of lipids, HbA1c and alcohol consumption. There are also newer indicators for cancer reviews by 3 and 24 months and annual blood sugar checks for patients with non-diabetic hyperglycaemia.
Vaccinations and immunisation remains a difficult area for many practices and I don’t expect to see that changing this year. Ultimately, it will be for practices to decide what is appropriate, feasible and viable to offer in this area.
Key action points
- Review your coding of children’s MMR vaccinations as a matter of urgency. Where achievement is unexpectedly low check which codes are being used.
- Search frequently for children approaching the age of eight months, 18 months and five years to identify eligible patients to call for vaccinations before the deadline.
- Focus on indicator NDH001 for the rest of the year (2021/22) in order to maximise points and income.
- Call up your 79-year-olds to invite them for shingles vaccination if they have not already had one.
QOF in numbers
- 582.4 was the average practice achievement score (out of a maximum of 635) although payments for most indicators will be based on historical points.
- 1.5% of practices achieved a maximum score of 635 points, compared with 6.2% of practices in 2020-21 who achieved a maximum score (567 points).
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website