QOF: how payments are calculated – and why prevalence matters

Practices’ achievement in the Quality and Outcomes Framework (QOF) is measured in a number of ways – the number of patients who met a target, the number of points a practice is awarded at the end of the year or the amount of payment a practice is awarded.

How do these factors relate to each other and what can be done to maximise the financial benefits of QOF?

How payments are calculated

Payment is calculated from computer records as at 31 March each year (although the data may not actually be sent and processed until a couple of days after).

The basic method is to pay practices a set amount per QOF point attained, depending on the size of the practice.

For 2021/22 the payment for an average practice, based on a list size of of 9,103 patients, is £201.16 per QOF point.

it is worth noting that the average practice size has increased every year and the value of a point has risen alongside it. Often the headline value of a point will have risen quite a lot, but much of this increase is offset by the increase of the average list size.

There are two ways that the points value is calculated, although each approach uses the same principles.

1. Simple payments for points achieved

For some QOF areas the payment is simply based on how many points are awarded and the size of the practice. In normal times, this applies for the new Quality Improvement (QI) indicators.

So, an average-sized practice will be paid at the rate of £201.16 per point. The average practice, if it earned all of the 74 available QI points, would receive £201.16 x 74 = £14,885.84.

A practice half this size (4,550 patients) will be paid at half the rate and receive around half the amount above – about £7,443 – for getting the same 74 QI points.

Conversely, a practice double the average size (18,200 patients) would receive twice the amount – about £29,800.

The only way to boost your achievement and thereby payment in these areas is to make sure you achieve all the points available.

2. Payments adjusted for prevalence

Most clinical areas are a little more complicated. In each disease area (apart from four exceptions), the value of a point is adjusted to reflect the prevalence of that disease, ie the proportion of the practice list that is affected, and therefore the burden of that particular disease on the practice.

Practices with higher than the national average disease prevalence will receive more money per QOF point than those with a disease prevalence lower than the national average.

The prevalence adjustment is used to try to reflect the relative amount of work a practice has to do to achieve targets in a given disease area.

Exceptions where disease prevalence doesn’t apply are the blood pressure indicators, palliative care and one smoking indicator, while the cervical screening indicators have a different ‘target population factor’ applied.

How is it calculated?

The payment is calculated relative to the number of patients affected in a typical practice of average list size of 9,103 patients.

For example, in 2021 the prevalence of diabetes nationally was 5.8%, and the average number of patients with diabetes was 530 per practice.

So, for an average-sized practice with 530 patients on its diabetes register, each point would be worth £187.74.

The same size practice with only 53 diabetes patients (a 10th of 530) would receive only £20.12 per point (we have divided by 10).

Why your disease register matters

Each disease area has a register of patients with the condition, and usually this is rewarded in QOF with a separate indicator (indeed, for some areas, it is the only indicator). In other disease areas, for instance depression, the register is less visible as it does not have an associated indicator.  But these ‘hidden’ registers will still affect the value of a point in that disease area in the same way as an explicit register.

While the indicators describe maintaining a register, the number of patients on a disease register is calculated automatically from diagnoses coded on the practice computer system.

Nonetheless, it’s important for practices to ensure they code up their patients accurately to ensure all relevant patients are included. This is particularly important when you consider your practice may be providing all of the correct care processes for a given patient, but if the patient is not recorded you won’t be paid for that work.

Working out how much an additional patient is worth to your practice

It is possible to estimate the amount of income that would be earned by adding another patient to the disease register, assuming a practice had achieved all the available points.

The guides on Pulse Intelligence use data from previous years, together with the latest changes to QOF indicators, to make income estimates in each of the disease areas.

(As the average number of patients with a disease diagnosis is not known until after the end of the year, the exact payment is not known until QOF data from all practices has been submitted.)

How Pulse Intelligence comparisons help to boost prevalence-related payments

Most practices earn almost all of the available points so the differences in income between your practice and peer, CCG or national averages for each area are largely down to differences in the number of patients on disease registers.

This may simply reflect differences between practice populations, but a low register size can also be due to patients not being coded correctly. Comparing your prevalence with the 80th centile for national or CCG prevalence can help to identify where you may have lower than optimal prevalence and therefore be missing some patients from your register. As above, often these patients are already receiving effective treatment, so it’s important to add them to a disease register to ensure the practice is paid for work that it is already doing.

Adding a patient to a register with all points earned can be valuable. Simply recording a BMI of over 30 will place a patient on the obesity register, which is worth a payment of about £2. There are four other areas where there is no other QOF requirement other than having a register. Correctly coding a patient with left ventricular heart failure can be worth nearly £125.

Clearly, adding just a few patients to these registers can more than pay back the time spent adding the correct codes. All of these rules work for the majority of indicators. There are always some exceptions, although these are relatively minor and are explained in the individual disease area guides.

How thresholds impact your payment

Practices may not be able to achieve maximum points on every indicator.

Achievement for most indicators is calculated as the number of patients who meet certain criteria divided by the number of eligible patients.

For example, a simple hypertension indicator will measure the number of patients who have a blood pressure measurement below the target level divided by the number of patients on the hypertension register.

But the indicator may also have lower and upper thresholds – the lower is the level of achievement at which points will start to be awarded. The higher is the level where the maximum number of points are awarded.

In general, the lower level is 40% or less below the upper and is not below 40%. You can see how this works in points awarded for DM022 (statin prescriptions in diabetes). There are no points for the first 50% of patients who have a statin prescribed. The points then go up as more patients have a prescription until a 90% threshold is reached, where the maximum of four points is earned. Achieving above 90% will have no effect on the points total – and hence no effect on payment.

The thresholds can vary quite widely between indicators without any obvious pattern, and there is no way to know what they are without looking them up.

As a practice will not receive points until achievement reaches a threshold of 40% or more, it can take a while to get any points at all. At the start of the QOF year you are likely to find the only points you have been awarded are for keeping disease registers. It might take until halfway through the year before you see further points being awarded.

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

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