Revised QOF guidance for 2020/21 – a summary

A summary of all the refocused QOF areas and indicators, detailing which indicators will count, how the points will be allocated, where income protection applies and the changes to this year’s Quality Improvement modules.

NHS England has published guidance on the revised QOF for 2020/21. This has confirmed the following indicators will continue to be paid on the basis of practice performance:

• The four flu indicators for patients with coronary heart disease, COPD, stroke/TIA and diabetes – the number of points attached to these is doubled.
• The two cervical screening indicators, which also have the number of points attached to them doubled.
• Register indicators, and eight indicators related to optimal prescribing of medications to manage long-term conditions.
• The Quality Improvement (QI) domain modules, which have been amended to focus upon care delivery and restoration of services using QI tools.

The remaining 310 points will be subject to income protection based upon historical practice performance and subject to practices agreeing an approach to QOF population stratification with their commissioner.

The total points available to practices will remain at 567 points and the value of a point is still £194.83; all payments continue to be subject to prevalence and list size adjustments.

 Flu and screening indicators – points allocation 2020/21

Points for flu vaccination and cervical screening are doubled, as detailed in the below table. This has been achieved by reallocating 29 points from other clinical indicators.

The payment formula has also been amended so that points are no longer allocated on a linear scale from 0 points to maximum points between the lower and upper payment threshold. Instead a set number of points is achieved as soon as the lower payment threshold has been passed, with the remaining points being achieved in a linear manner between the lower and upper threshold.

The guidance reminds practices that as part of the Impact and Investment Fund (IIF) for 2020/21, Primary Care Networks (PCNs) will receive additional funding for achieving between 70% and 77% flu vaccination coverage of patients aged 65 and over.

Indicator	Points	Payment thresholds	Points accrued at lower performance threshold
CS005 The proportion of women eligible for screening and aged 25-49 years at the end of period reported whose notes record that an adequate cervical screening test has been performed in the previous 3 years and 6 months	14	45-80%	3
CS006 The proportion of women eligible for screening and aged 50-64 years at the end of period reported whose notes record that an adequate cervical screening test has been performed in the previous 5 years and 6 months	8	45-80%	1
COPD007 The percentage of patients with COPD who have had influenza immunisation in the preceding 1 August to 31 March	12	57-97%	3
DM018 The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March	6	55-95%	2
STIA009 The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 August to 31 March	4	55-95%	1
CHD007 The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 August to 31 March	14	56-96%	3
Total	58

Register Maintenance

Practices must maintain accurate disease registers in QOF for 2020/21 as outlined in the below table.

Payment is conditional on continuing to accurately maintain these registers and for disease prevalence to remain comparable with 2019/20 levels – subject to ‘reasonable assessments of the impact of excess COVID-19 related mortality upon practice list size, patient demographics and access to diagnostic services’.  

The guidance acknowledges that ‘in some areas access to diagnostic services may have been disrupted’. Practices are advised to ‘use their clinical judgement in the management of these patients and the point at which they are added to QOF registers’.

Indicator	Points
AF001 The contractor establishes and maintains a register of patients with atrial fibrillation	5
CHD001 The contractor establishes and maintains a register of patients with coronary heart disease	4
HF001 The contractor establishes and maintains a register of patients with heart failure	4
HYP001 The contractor establishes and maintains a register of patients with established hypertension	6
PAD001 The contractor establishes and maintains a register of patients with peripheral arterial disease	2
STIA001 The contractor establishes and maintains a register of patients with stroke or TIA	2
DM017 The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed	6
AST005 The contractor establishes and maintains a register of patients with asthma aged 6 years or over, excluding patients with asthma who have been prescribed no asthma related drugs in the preceding 12 months	4
COPD009 The contractor establishes and maintains a register of: 1. Patients with a clinical diagnosis of COPD before 1 April 2020 and 2. Patients with a clinical diagnosis of COPD on or after 1 April 2020 whose diagnosis has been confirmed by a quality assured post bronchodilator spirometry FEV1/FVC	8

Prescribing indicators

Payment for the following eight optimal prescribing indicators continues to be conditional on recorded practice performance.

Indicator	Points	Payment thresholds
AF007 In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anti-coagulation drug therapy	12	40-70%
CHD005 The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken	7	56-96%
HF003 In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB	6	60-92%
HF006 The percentage of patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, who are currently treated with a beta-blocker licensed for heart failure	6	60-92%
STIA007 The percentage of patients with a stroke shown to be nonhaemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anticoagulant is being taken	4	57-97%
DM006 The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs)	3	57-97%
DM022 The percentage of patients with diabetes aged 40 years and over, with no history of cardiovascular disease and without moderate or severe frailty, who are currently treated with a statin (excluding patients with type 2 diabetes and a CVD risk score of <10% recorded in the preceding 3 years)	4	50-90%
DM023 The percentage of patients with diabetes and a history of cardiovascular disease (excluding haemorrhagic stroke) who are currently treated with a statin	2	50-90%
Total	44

Revised Quality Improvement modules

The Quality Improvement (QI) modules for this year, on early cancer diagnosis and learning disabilities, have been amended to ‘support practices to focus on actions to help with the restoration of care delivery’.

The revised requirements do not replace QI activity that practices have already started but provide a set of national actions which practices should undertake to revise their approach as a result of the pandemic.

For each of the modules, practices will be awarded 27 points for demonstrating continuous quality improvement activity in the area as set out in the QOF guidance, and a further 10 points for participating in network activity to share and discuss QI activity in these areas.

Early diagnosis of cancer
The focus for cancer is on restoring delivery of cervical screening services and ensuring patients who need urgent referral are identified, supported and managed in line with NICE guidance.

Practices are expected to bear in mind health inequalities and target populations where they have seen a particular drop in take up.

Practices should:

• Restore cervical screening and actively identify women who have had their cervical screening appointment delayed or cancelled due to COVID-19 and ensure that they are offered an appointment.
• Proactively engage with local populations so that they understand that general practice is safe and they can come forward for appointments if they have concern.
• Monitor their suspected cancer referral rates and assess if these are returning to their previous levels seen before COVID-19. Practices should also reflect on the quality of referrals and whether these follow NICE guidance on suspected cancer and whether they could improve awareness of referral and testing pathways.
• Ensure they have a robust safety netting system in place.

Learning disabilities

The national quality improvement actions for care of people with learning disabilities are focused upon the restoration of proactive annual health checks and ensuring that seasonal flu vaccination is maximised in this group.

Practices should:

• Review and update their registers to ensure accuracy.
• Restore all annual health checks for people with learning disabilities.
• Develop and implement a plan to improve flu vaccination uptake in this group.
• Record the need for and type of reasonable adjustments that are required and evidence that these are being implemented.
• Review all DNACPR decisions and confirm they are appropriate and continue to be clinically indicated.

Income protected indicators

Practices will be offered income protection for the remaining 310 points, subject to the delivery of revised and simplified requirements focused upon care delivery to those patients at greatest risk of harm from COVID-19, uncontrolled long term condition parameters and those with a history of missing reviews – with practices being credited with points on the basis of historical achievement.

Performance against these indicators will be monitored through CQRS but will not be used for payment purposes.

To be eligible for income protection practices will need to:

• Agree a plan for QOF population stratification with their commissioner during October and November 2020. This approach should include the identification and prioritisation of the highest risk patients for proactive review including: a. Those most vulnerable to harm from COVID-19; evidence suggests that this includes patients from BAME groups and those from the 20% most deprived neighbourhoods nationally (LSOAs) b. those at risk of harm from poorly controlled long-term condition parameters; c. those with a history of missing reviews.
• Commit to making referrals to existing and any new weight management programmes and support offers commissioned during the year where this is identified as a key health and wellbeing intervention in these discussions.

Practices will be asked to confirm their approach to population stratification via the General Practice Annual electronic declaration (eDEC) which will be published during October and November 2020.

Alerts should be kept active, including for indicators that are income protected. This will help to ensure that practices are able to provide and record opportunistic care, where appropriate to do so, including any personalised care adjustments (exception reports).

Further reading

NHS England/ BMA. 2020/21 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF)

PHE NHS Cervical Screening Programme Restoration Guidance

Cancer Research UK – Healthcare professional Covid-19 and cancer hub including Safety netting guidance for general practice

RCGP – Health checks for patients with learning disabilities toolkit