Practices’ QOF achievement for 2019/20 has been published early this year, demonstrating a dip in the number of points achieved for the first time in some years. GP and QOF expert Dr Gavin Jamie describes the topline results and what the changes likely reflect.
NHS Digital has been busy since April and has published the QOF results for 2019/20 a full two months earlier than in previous years.
Achievement remained high – the average practice earned over 544 points, or 97% of those available. However, this is about six points (1%) lower than the previous year. It has been some years since we have seen a drop in the number of points achieved by practices.
The QOF data was taken from practice systems as usual at the end of March – just after the lockdown began and a few weeks after practices had started to move to telephone triage of all appointments. At the time practices were also promised protection of their QOF income based on the previous year’s income. These figures are still important, as they are likely to inform the calculation of the more extensively protected 2020/21 QOF payment.
Changes to how practices operated only began in March – the vast majority of the QOF year took place as normal. Most differences in activity are therefore only likely to have been in the final polish that practices usually give to the results at year-end, and the effects on QOF scores appear to have been small.
What has had a more significant impact is the introduction of some tough new indicators into QOF in 2019/20. Around a quarter of the points decline was seen in the diabetes area where new, and challenging indicators had been introduced. The HbA1c targets were more difficult to hit and this was compounded by a reduction in exception reporting by practices, most likely at the end of the year. The largest drop in achievement was for patients having an HbA1c of less than 58 mmol/molHb – around 5% fewer patients achieved this indicator. This is likely to reflect the reduced glucose threshold (it was 59 mmol/molHb last year) and the reduced opportunity to test.
Hypertension also saw the introduction of new indicators in 2019. Previously practices had earned points for patients with hypertension whose blood pressure was under 150/90 mmHg. Now this threshold had been dropped to 140/90 mmHg for patients under 80 years old and practices lost an average of 1.7 points due to this change.
Similar changes were made to blood pressure thresholds in the stroke and cardiovascular disease areas, although the effect on points was smaller.
There were also small reductions in other areas which seem to be related to lower levels of personal care adjustments (formerly known as exception reporting) – again most likely due to practices having other things to do at the end of March.
The new Quality Improvement indicators carried a lot of points and had very high levels of achievement. Fewer than 20 practices in the whole country lost any points on these indicators.
Disease prevalence mostly continues previous trends. Practices are continuing to identify more patients with diabetes and atrial fibrillation. This is likely to represent ongoing awareness of these conditions. Diabetes has now increased by 66% since 2005 and there has been a similar rise in the prevalence of atrial fibrillation.
There also continues to be a rise in the proportion of patients recognised as obese although, at 8.4%, it is still rather lower than other surveys would suggest.
Perhaps because of the treatment of these patients the prevalence of coronary heart disease and peripheral vascular disease continues to fall each year.
The asthma register has been fairly steady over its 16 years in the QOF with only a very gradual increase over that time. Things were a little different this year and an extra 300,000 patients appeared on the register, representing a rise of over 7%.
The reason for this increase is the way that the asthma register is generated. Patients need not only to have a diagnosis of asthma but also need to have been prescribed asthma medication during the QOF year. In March 2020 nearly a million more salbutamol inhalers were dispensed in England compared with the year before. This seems to have caused a sudden rush of patients onto the register, although it does not seem to have affected achievement in this area.
Practices should take pride in their achievement this year. They have continued to have a very high level of achievement despite tougher targets and some disruption to usual practice.
There is some income protection for 2019/20 – guaranteeing practices a minimum of their 2018/19 income – although it is not clear how useful that has been. As practices merge or close most list sizes are rising. Although the size of the list increase is very variable it averages about 2.5% – rather larger than the 1% drop in points achievement. Practices with a rising list are likely to find that their actual 2019/20 QOF earnings are larger than their protected income, although it is still less than they might expect in a normal year.
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF database website
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