Maximising your QOF income: Smoking

Updated November 2022

Summary – indicators and value

• Indicators: 3
• Points: 62
• Prevalence* (indicators 1 and 3): 22%
• Estimated £/patient: See individual indicators below

*Prevalence is an estimate based on latest available QOF data and current trends. For further explanation read more details here.

There are a lot of points available for smoking advice, although the number of patients also tends to be very large, reducing the relative value per patient. The QOF statistics suggest that more than 20% of adult patients are current smokers, although this varies significantly between different parts of the country.

NHS England has reduced the number of indicators in recent years. For example, there is no longer an indicator for recording smoking status in patients without a chronic disease. This means less to do, but it can also mean it is sometimes less obvious what is going on behind the scenes.

The majority of the points available in smoking still relate to patients who have been diagnosed with chronic diseases. These patients may also appear on the stroke/TIA, CHD, peripheral arterial disease, asthma, COPD, hypertension, diabetes, CKD, or the mental health registers. This area is mainly restricted to adults, although this varies by diagnosis.

Indicator 1: Smoking status recorded in patients with chronic disease (25 points)

• £/patient (estimated): £2.50 

Payment for this indicator will be around £2.50 per patient if 90% of patients with chronic disease have their smoking status recorded. Prevalence adjustment for this indicator is based on the number of patients who are on one of the chronic disease registers as listed above. Each patient will be counted once, even if they appear on multiple registers.

Patients should be coded with either their current smoking habits, a record of having never smoked tobacco, or being an ex-smoker. A record of passive smoking does not apply for these indicators.

Only codes entered after the patient’s first date of diagnosis will be considered.

There are two ways that this annual coding can be avoided:

• The first is if the patient has a code of having never smoked tobacco after their 25th birthday. This is because it is considered unlikely that someone will start smoking for the first time in their late twenties.
• The second is that a patient is coded as being an ex-smoker over three successive years (with at least a year between the codes). Here it is also considered unlikely that they will start smoking again and no further records are required.

Automatic exception reporting (which now comes under the new ‘personalised care adjustment’ approach) applies to patients who have registered with the practice in the last three months of the QOF year, and there are exception codes where the patient has refused to give their smoking status, or is unsuitable for other reasons, such as terminal illness.

Indicator 2: Smokers offered treatment in the previous two years (12 points)

• £/patient (estimated): £1.90

This indicator applies to all smokers over 15 years of age. The most recent smoking status code is used to determine the patients that should be considered.

There are two ways to achieve this indicator:

• The first is to code smoking cessation advice given or referral to a smoking cessation service.
• The second is to prescribe a smoking cessation medication such as nicotine, varenicline or bupropion.

This indicator is likely to apply to a large number of patients and certainly does not supply the funding for a full smoking cessation service, averaging at around £1.90 per smoker.

Tips:

• Opportunist advice and referral are likely to the most effective way of getting to the 90% of patients needed to get the full 12 points.
• Invitations don’t have to be in person but should be personalised. A letter or telephone call – and potentially a text – would be acceptable, but a poster in the waiting room would not be.
• Keep your smoking data up to date. Patients are considered smokers based on their most recent record, even if that was 10 years ago.

Indicator 3: Smokers with chronic disease offered treatment in the previous year (25 points)

• £/patient (estimated): £15

This indicator is very similar to the previous, but only applies to smokers who have chronic diseases and the advice must be repeated every year. The smaller number of patients and the high point count mean that each patient carries more points, although the upper threshold is a demanding 96%.

Each smoker is worth about £15.

Tips:

• Smoking cessation should be an integral part of annual reviews for chronic disease.
• Set up your IT system so that when a code indicating smoking is entered, the smoking cessation template automatically appears.
• Consider using a mailing company for sending larger quantities of letters. It can be more cost effective and is definitely better than stuffing envelopes. Texts can be used, as long as they include the detail.

Exception reporting (now ‘personalised care adjustment’) is limited to patients who refuse to give their smoking status, are unsuitable or give informed dissent. Patients are also automatically excepted if they have registered with the practice or been first diagnosed in the last three months of the QOF year.

Removed in 2019/20:

There is no longer an indicator for providing literature and therapy in the practice. This is regarded as a core professional practice.

Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website

Further reading/resources

• NHS England – Quality and Outcomes Framework guidance for 2022/23. Published 31 March 2022.

Full indicators

Indicator 1: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months (SMOK002) Payment threshold: 50-90% 

Indicator 2: The percentage of patients aged 15 or over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 24 months (SMOK004) Payment threshold: 40-90% 

Indicator 3: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months (SMOK005) Payment threshold: 56-96%