GP Dr Gavin Jamie reviews how surgeries performed in QOF last year and on changes to prevalence, as well as suggests tips for improving income this year
Although practices will have known their own QOF results since April, NHS England has now published the QOF achievement for all practices. There were no changes to the QOF indicators for 2022/23, but it was the first year for a while where there was no element of protection for achievement.
The effect of that loss of protection has been an overall fall in achievement by an average of 1.5 points. This masks some of the detail including a drop nearly 10 points in the clinical domain – with five of these points affecting a single indicator in the Asthma area, AST006.
While this represents a relatively small percentage drop, each point was typically worth £207 and so losses can represent a significant sum.
Analysis of QOF activity for 2022/23 revealed that:
Asthma indicator AST006 saw a drop in points achievement
This is a tough and complicated indicator requiring patients who are newly diagnosed with asthma to have testing with spirometry and either reversibility of FeNO.
It has proven practically difficult for practices to implement and despite a fall of five points as a result of protection during the Covid era no longer being applied, it does not reflect the rapid rise in achievement in this indicator in the last couple of years.
Average achievement has risen from 12% in 2020/21 to 62% in 2022/23.
This indicator has been tweaked for 2023/24 and the clock reset so that low achievement in the last couple of years will not affect the outcome this year. There is every opportunity to make up lost ground here.
Practice performance for this indicator last year tended to be either high or low with few achieving somewhere in between suggesting that success was down to having good processes within the practice.
It is vital to have a policy that meets the testing requirements for patients who have a new diagnosis or who have newly registered without all of the appropriate investigations.
Mental health was challenging
Mental health is another area that seems to have been challenging for practices. There have been new indicators over the last couple of years regarding annual reviews and physical checks.
There are 34 points to be gained overall for annual reviews and care plans and, on average, practices missed out on about 3.5 points. As most of these checks can occur at the same time achievement is pretty consistent although documenting the care plan and getting the blood tests for cholesterol and HbA1c had slightly lower rates of achievement than the others.
There are no extra points or requirements in 2023/24 for mental health but there is a new indicator, MH021, that covers all the checks being done and will therefore amplify the effect of missing any of them. Not only will practices miss the indicator for the individual check but they will also miss the composite indicator as well.
It will be very important that patients are invited to have these checks and that the invitation is coded in their record. Hopefully two invitations should encourage them to attend but, if not, those two invitations will except them from these indicators.
Public health indicators dipped
A few points were lost in the public health area, mostly around blood pressure measurements in patients over 45 years old and on smoking status recording.
The blood pressure indicator looks back over five years and, over recent years, there have been fewer chances to opportunistically check patients’ blood pressure. This has caused a dip in this indicator.
Less explicably, there has also been a drop in smoking status recording in patients over 15 years old. This is easily done over the phone or by online questionnaire.
Both of these should be incorporated into routine and opportunistic checks.
Vaccinations achievement rate was low with points attainment at just over half the maximum
Vaccinations and immunisations are difficult indicators that were introduced in the previous year. On average practices gained two extra points here but the overall achievement rate remains low at 35.5 points out of 64. As before, the shingles vaccinations earned full points for almost all practices although the underlying achievement rate jumped significantly.
Preschool vaccinations proved to be the most difficult for practices with a vaccination achievement rate of 81.8%. Due to the way that points were awarded this translated into an average point score of 7.5 out of 18 – significantly less than half of the points. There is a very wide variation in performance between practices, with nearly half (47%) of practices getting no points at all for pre-school vaccinations.
These vaccinations will still have attracted item of service payments (£10.06), so practices will have received some payment but it is likely that QOF points, where achieved, will have significantly greater value than the IoS payment.
The indicators for infant and 18-month vaccinations are a bit better but practices still only gained about half of the points available despite achievement being rather higher at around 90% of children vaccinated.
Overall achievement on the vaccine indicators had increased since the previous year. If that continues, and with the changes this year to the thresholds and a possibility of some limited exception reporting, we can reasonably hope to see a further increase in points scores in the coming year.
There have been notable increases in prevalence in obesity and non-diabetic hyperglycaemia
It is not just the point score that determines QOF income. Prevalence adjustments account for most of the differences in payments between practices.
The largest increase in prevalence this year was from the obesity register, which was 1.7 percentage points higher than in 2021/22. Although the general trend is upward, this sharp increase is an artefact of the pandemic as we had a couple of years when fewer patients were being weighed in the surgery.
The mental health register had also seen a dip and subsequent recovery over the couple of years of the pandemic. Depression remains at a constant level while dementia diagnoses saw a dip from which there has not yet been a full recovery. The reason for the latter is not clear.
This is the third year that non-diabetic hyperglycaemia (NDH) has been part of QOF and there has been a rapid rise in the recorded prevalence from 4.2% in the first year to 5.7% at the end of March 2023. The prevalence of diabetes has been rising more slowly and going on current trends, by March 2024 we may well see NDH become a more common diagnosis than diabetes. Overall, it is likely that we will see one in six adults having a coded diagnosis of either diabetes or NDH next year.
We can see the results of hard work against cardiovascular disease with coronary heart disease continuing its long-term decline and peripheral arterial disease going the same way. This is not the case with stroke and TIA which has gradually increased, although only very slowly.
Heart failure has been increasing gradually in prevalence over the last few years. I suspect that this is because we are better at recognising the condition rather than a true increase in prevalence. The most common underlying cause is coronary heart disease and the prevalence of that is declining. We have seen a much faster rise in the proportion of patients in the subset of patients marked as having left ventricular systolic dysfunction. Adding this code makes patients eligible for the two prescribing indicators, ACE inhibitors and Beta blockers. It also increases the prevalence for these two indicators. As they carry nearly half of the heart failure points for a subset of patients this can be worth over £60 per patient.
COPD had previously been rising although it seems to have peaked in 2020 and has gradually fallen since then. Whether this is a real effect or the result of other changes over the last couple of years remains to be seen.
The future of QOF is being debated at the moment, a debate that has been running on and off for at least a decade. While it’s still in place, we continue to see a strong record of the delivery of mostly evidence-based care to patients. The pandemic is still making its presence felt in these figures but the dominant message is of recovery and the preservation of services to patients.
This is another set of QOF results of which GPs and practices should be proud.
Key action points for QOF work 2023/24
- To improve performance in asthma, practice processes are key. Have a policy that meets testing requirements for patients who have a new diagnosis or who have newly registered without all of the appropriate investigations.
- Make sure eligible patients are invited to have all the checks required under the mental health indicators and that invitations are coded in records.
- Blood pressure recording in over 45s and smoking status recording should be done as part of routine and opportunistic checks.
QOF in numbers
- A QOF point had a value of £207.56, an increase of 3.2% compared with 2021/22 although adjustments to average list sizes meant that there was no increase in cash terms.
- A total 4,009 (62.9%) of practices achieved over 90% of the available QOF points.
- The COPD indicator group had the highest personalised care adjustment (PCA) rate at 24.1%.
Dr Gavin Jamie is a GP in Swindon and runs the QOF database website
