Published 12 August 2021
QOF expert Dr Gavin Jamie provides a timeline to help you schedule work to meet all the indicator requirements for 2021/22
In the past work towards the QOF could be done at any point during the year.
Very organised practices would space the work out throughout the year, while for many there would be a mad rush as the end of March approached. Most practices would do a bit of both.
While this is still the case for a lot of indicators, an increasing number now require work to take place all through the year and will need to be regularly reviewed. In most of these cases, the patients cannot be identified at the start of the QOF year and the window for action may have closed before the end.
Most of these clocks start at the time that the diagnosis has been made. Knowing these requirements and having a system to schedule appointments to deal with them at the time of diagnosis will allow most patients to get the care that fulfils the QOF requirements.
Inevitably some patients will slip through, however, either through patient non-attendance, simple error or the diagnosis being made elsewhere. The simplest way to tackle this is to set up searches that are run on a schedule and a timetabled session to check the results. In my practice we call these ‘Red Alerts’. The goal of these searches is to find patients who meet the criteria in the appropriate timescale and then to exclude those who have already had the intervention.
When writing searches, there may be some pre-made rules in your clinical system – particularly for finding patients on disease registers. Using these or bespoke searches from third party companies can make the process easier.
Here are some tips on the actions you need to take at least every other week, at least every month and bimonthly, as well as some dates to schedule more infrequent tasks.
DEP003 – Patients with a new diagnosis of depression need a review between ten and 56 days after diagnosis. Searching for all patients with a diagnosis more than 28 days ago and no review should give an action list of patients who have possibly missed it. The next step should be to contact them and arrange a review in good time.
CAN005 – Patients should have a discussion and offer of support services within three months of the diagnosis. Finding patients who have not had this review by eight weeks after the date of diagnosis will give you four weeks to arrange it; these patients should be contacted as soon as possible (a telephone call for the review is fine).
Sometimes there can be quite a time lag between diagnosis and discharge from hospital following treatment – nevertheless, the review window starts from the date of the diagnosis. That can mean that you have much less than twelve weeks after discharge.
VI001 – All infants should have had three DTP doses by eight months of age. There is no way to do this if they have not at least had the first dose by six months. Identify children who have not had a first dose by age four months or a complete course by six months and invite them for vaccination. This could be by a search or via your normal recall system.
VI002 – Children should have MMR by 18 months. Finding any without a vaccination at 16 months will allow time for a further vaccination invite to be sent. They should appear on your recall list but it is also relatively easy to search for an MMR vaccination code in children between 16 and 18 month old.
AST006 – Confirmatory tests for asthma need to happen within six months of diagnosis. Usually this will happen at the point of diagnosis. Set up a search to find patients who had a diagnosis more than four months ago but have not had the confirmatory tests, to get them organised before time runs out.
Newly registered patients will also need the tests if they have not been recorded before, so also search monthly for new patients with asthma, and make sure the tests are organised within six months.
COPD009 – There are similar confirmatory tests for patients diagnosed with COPD or who are newly registered, which should happen by six months. These are specified in the guidance although the actual business rules are more relaxed, so they are not absolutely essential for the QOF points. They are expected to be done as best practice but will not actually affect your point score or register size.
The tests are most likely to be missed in newly registered patients. When a patient’s previous records arrive, any investigations should be coded. If the investigations have not happened, or the notes do not arrive, then spirometry should be carried out within six months of registration.
New patients with COPD (or indeed asthma or heart failure) are relatively easy to identify with a search.
HF005 – Once again there is a six-month window for either an echocardiogram or referral to a specialist, so search for patients with a diagnosis over four months ago but no confirmatory tests coded. This applies to new diagnoses and newly registered patients if they have not already had an echo. Remember even just the referral for an echo will count towards QOF, if it is correctly coded.
DM014 – All patients over 17 should have referral to a structured education programme within nine months of the diagnosis. Usually this would happen around the time that diagnosis has been made – check that this has happened by searching for the referral codes more than six months previously. If there has not been a referral this could be discussed with the patient by phone and the referral arranged in time.
MMR pre-school (VI003) – All children who are four years old at the start of the year should have had two MMRs and a DT booster which will count for this indicator at the end of the year. They must have the vaccinations before their fifth birthday.
There is a bit more time for this than other vaccination indicators but they should be identified through a search or the recall list. Searching for three vaccinations in appropriate timescales is more complicated than some of the other searches. The aim is to find all four year olds without the appropriate vaccinations. Recall lists from the local health authority may be easier to deal with.
Running the search every two months or examining the list should give plenty of time to arrange an appointment for the vaccines. It may also identify ‘ghost’ patients who should be removed from the practice list.
VI004 – In a similar way, all patients who are 79 at the start of the year should have a shingles vaccine and the vaccine should be given before their 80th birthday. Running a search at least every couple of months for all 79-year-olds who have not had the shingles jab should help to bring in as many as possible before they turn 80.
Unlike the other vaccination indicators there is the opportunity for patients to record dissent from the vaccination, although this is not automatic following invitations. A code will need to be entered if the patient explicitly says that they do not want a vaccination or does not respond to two invitations.
OS004 – Getting patients onto the osteoporosis register can be a complicated process. Review all fractures from the previous two months to judge whether they are fragility fractures and require DXA scanning or an osteoporosis diagnosis. This will lead to an increase in your osteoporosis prevalence which can be worth over £20 per patient.
Ideally you need a system to look at letters from A&E to identify potential fragility fractures, but a search for fracture codes can also help.
NDH001 – Review all patients who have an HbA1c result in range for non-diabetic hyperglycaemia (NDH) – they will need an explicit diagnosis code to be entered so that they appear on the NDH register. The search should find all patients who have an HbA1c result between 42 and 47mmol/mol in the previous two months, but exclude patients already on the diabetes or NDH registers. In most cases these patients should have a ‘non-diabetes hyperglycaemia’ code entered.
BP002 – All patients over 45 years old should have a blood pressure check every five years. If they have not had a BP measurement in the last four years, it might be time to call them for a check. In many cases this could be done as part of an NHS health check.
Most indicators go to zero in April so it is time to start again.
It is useful to calculate your CHA2DS2-VASc scores (AF006) early in the year to identify all patients who will require anticoagulation before the following March (AF007).
The obesity register also goes to zero overnight so have a plan to weigh as many patients as possible again. The register is not really worth enough to justify calling patients in, but increasing staff awareness of the need to weigh all patients with a potential BMI of over 30 will pay off. This can be at annual reviews or just opportunistically.
Computer systems are better at calculating a BMI automatically from the weight but will obviously need a height recorded as well at some point. There are also reminders available.
For most of the prescribing indicators (the exception being aspirin in coronary heart disease) only prescriptions after 1 October count. Avoid over-long prescriptions to ensure that a prescription is made between now and March. If patients are having long term repeatable prescriptions ensure that they have at least one issue in this period.
Checking prescription issues can also help to identify patients who are not taking medication as it is intended.
Exception reporting (or personal care adjustment) can be done now if you have made, and coded, two invitations. Find patients who have not received an invitation or simply not been coded while there is still time to get through the process.
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website
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