GP Dr Gavin Jamie explains what activity to focus on for the new QOF year
There have been quite a few adjustments to QOF this year, despite the GP contract still being part of the five-year deal. The changes are perhaps a little less dramatic compared with other years but there’s certainly no let up.
One thing that has been frozen is the effective payment per point. This has stayed the same, with no inflationary uplift, for at least five years.
The following are the headline points to address in order for practices to perform as best they can:
There are two completely new indicators, although they are unlikely to represent a large change in how practices work. Cholesterol management has been a part of the QOF since the very start with indicators that have waxed and waned over the years.
The first is:
CHOL001. Percentage of patients on the QOF Coronary Heart Disease (CHD), Peripheral Arterial Disease, Stroke/TIA or Chronic Kidney Disease (CKD) Register who are currently prescribed a statin, or where a statin is declined or clinically unsuitable, another lipid-lowering therapy.
This carries 14 points and requires statins for 95% of patients on the CHD, peripheral arterial disease, stroke, and CKD registers. In the past there might have been separate indicators in each of these areas but now there is a single, combined, indicator.
The diabetes area still has its own indicator for patients to be prescribed statins. Patients who are 17 years old and over with diabetes are specifically excluded from this new indicator, even if they have CHD etc.
Patients are also excluded if they are on the palliative care register. As there is quite a large overlap between cardiovascular disease and diabetes, the number of patients excluded may be considerable.
Patients may be exception reported under the personalised care adjustment if they have declined a statin.
The rules for adverse reactions are more complicated. Most patients will be prescribed a statin. The indicator will also include patients prescribed bempedoic acid, ezetimibe, icosapent ethyl, inclisiran or a PCSK9 inhibitor (antibody therapy) if, and only if, the patient has a recorded adverse reaction to a statin. This also means that recording an adverse reaction or allergy to a statin will not except the patient from the indicator.
Patients may also be excepted if they have a code indicating informed dissent or an adverse reaction to lipid lowering therapy in general.
The usual timescales apply with respect to prescriptions, which must be issued in the second half of the QOF year – prescriptions of six months or more may not be picked up by this indicator.
While patients with cardiovascular disease are likely to have a prescription for statins already, the number of patients with chronic kidney disease prescribed statins may be lower. This could be a group to concentrate efforts on at the start of the year.
Where patients are unable to tolerate statins there is now a much greater emphasis on the use of alternative medications. These patients may have been exception reported in the past and it is worth checking to see whether an alternative cholesterol lowering medication may be suitable.
The second new indicator is:
CHOL002. Percentage of patients on the QOF Coronary Heart Disease, Peripheral Arterial Disease (PAD), or Stroke/TIA Register, who have a recording of non-HDL cholesterol in the preceding 12 months that is lower than 2.5 mmol/L, or where non-HDL cholesterol is not recorded a recording of LDL cholesterol in the preceding 12 months that is lower than 1.8 mmol/L
There is quite a lot going on in this indicator, so I will break it all down.
At first glance, it looks quite like the other cholesterol indicator but there are some significant differences.
First, it does not include patients with chronic kidney disease. Second, it DOES include patients with diabetes or on the palliative care register if they are also on the CHD, PAD or stroke registers. That will mean that the population for this indicator is rather different to CHOL001.
Third, there is very little exception reporting currently available for this indicator. This may change through the year if a new version of the QOF business rules are published but currently patients are only excepted if they decline a cholesterol test or register with the practice after July in the QOF year. There would need to be a specific code recording a declined test (e.g. ‘Cholesterol test declined’) recorded to trigger that exception.
In the current set of business rules for 23/24, there are no exception reports for treatment allergy, informed dissent or being on the maximum tolerated treatment dose.
Otherwise, the indicator is as described with non-HDL being required to be below 2.5mmol/L or, if that is not available then LDL cholesterol should be less than 1.8mmol/L. Note that non-HDL will always take priority even if there is a subsequent LDL measurement. This may be significant if local lab reporting changes or if patients move between practices.
There are 16 points available and the thresholds are low, with points starting at 20% and the full 16 points for 35% achievement.
As this indicator uses codes that have not been in the QOF before it is worth checking that these are being recognised. These may be recorded directly from lab tests, point of care patient testing or by transcribing results from hospital letters. It is essential that any templates for manual entry are up to date.
Identifying patients with higher values, adjusting medication and retesting will take some time so it is important to start as early as possible to have the best chance of scoring highly in this indicator. There are 30 points in total available for the cholesterol indicators
Points reduction in other indicators
QOF has not expanded this year so points allocated to the cholesterol indicators means other indicators have lost out.
The indicator for rheumatoid arthritis reviews has been removed leaving that area with only a register that carries a single point.
The number of points for dementia reviews have also been slashed from 39 to 14. Dementia is still relatively well remunerated but this is still a significant cut to the funding for the condition.
AF008. Percentage of patients on the QOF Atrial Fibrillation register and with a CHA2DS2- VASc score of 2 or more, who were prescribed a direct-acting oral anticoagulant (DOAC), or, where a DOAC was declined or clinically unsuitable, a Vitamin K antagonist
This replaces a similar QOF indicator last year and also an indicator that was in the Investment and Impact Fund (IIF) last year. There is a change to the specification so that patients having warfarin, or another vitamin K antagonist, must now have a coded reason for not having a DOAC. This could be an adverse reaction or contraindication code.
There has also been quite a big rise in the payment thresholds for this indicator. Last year the full points value was awarded at 77%. This year it has risen to 95%.
The business rules are complicated as they need to deal appropriately with patients who have mechanical valve replacements or antiphospholipid syndrome. The key to hitting the high threshold will be meticulous coding of any patients who decline or have contraindications to anticoagulation.
Where patients decline anticoagulation separate codes for warfarin (‘warfarin declined’) and DOACs (‘Novel oral anticoagulant declined’) will be required.
If a patient is not suitable for anticoagulation in general then a single ‘anticoagulation contraindicated’ code will be sufficient.
Vaccines and Immunisations
There have been some tweaks to the vaccines and immunisations indicators this year. The thresholds have been expanded for the childhood indicators and the awarding of several points for hitting the lower threshold have been removed. This helps to reduce the very high payments for vaccinating some children with no payments for vaccinating others.
The clawback for vaccinating fewer than 80% of children has also been removed.
For practices who scored points before these changes are approximately neutral. Practices that were just below the thresholds are likely to see a gain.
Although there will still be no exception reporting allowed for parental refusal on vaccines, there will be automatic exception reporting where children have been registered with the practice too late to complete their course of vaccinations.
For example, VI001 concerns patients who reached eight months old having had three doses of a diphtheria, tetanus and pertussis (DTP) vaccination. Patients who have not been recorded as having three vaccinations at under eight months will be excepted if they:
- registered after eight months old, or
- registered after seven months with only 2 DTP, or
- registered after six months with only 1 DTP, or
- registered after five months with no recorded DTP.
Similar rules are in place for other vaccination indicators.
This is a well considered improvement to these indicators. Practices should remember that they will still get the item of service payment (frozen at £10.06) for each vaccination given including ‘catch up’ vaccinations given later than specified in the schedule.
These domains have changed annually (other than one year during the pandemic) and this year the two areas are ‘workforce and wellbeing’ and ‘optimising demand and capacity in general practice’.
The workforce and wellbeing indicators are in a format that will be familiar from previous years. There should be information gathering, identifying areas for improvement, two meetings at PCN level, a plan and some evidence that the plan was carried out.
The guidance is, as usual, extensive and reflects good employment practice including promoting equality and supporting staff appropriately. There is nothing wrong with any of this but it seems unlikely to be a step change in most practices.
Optimising demand and capacity in general practice is an ambitious set of indicators. There are 16 points for showing a recognised approach to demand and capacity measurement. There are a further six points for reviewing the smart cards of staff employed under the ARRS.
The remaining 15 points are for reducing avoidable appointments. Again, there is extensive guidance about collecting data and reviewing systems. While it may seem unlikely that practices are unaware of when they are busy and where demand exceeds capacity this will at least provide a more formal method of stating it. There should also be a consideration of inappropriate work which may also be a useful report to send to the ICB at the end of the year.
The clawback for vaccinating fewer than 80% of children has been removed. There is now automatic exception reporting where children have been registered with the practice too late to complete their course of vaccinations.
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website