After the wide-ranging changes to QOF in 2019, this year included a much more focused range of updates.
Each disease area is worth the same number of points as last year. The addition of extra detail and processes is the theme this year and the effect is likely to make reviews of asthma, COPD and heart failure to be more scripted.
At the time of writing we don’t know the full effect of adjustments to QOF due to Covid-19. It is quite possible that changes planned for QOF this year could have effects for several years in the future.
However, implementing what we do know as early as possible in the year could make things a lot easier later on.
You can read the full list of new/revised indicators here.
Below are the key changes to focus on to ensure your practice is well prepared for the changes and their likely financial impact.
Retired indicator – primary prevention
The single indicator for patients newly diagnosed with hypertension will be dropped from April. This rewarded the prescribing a statin to patients with a raised Qrisk2 score. This has been removed entirely in favour of a new pre-diabetes indicator (see below).
Changes to asthma indicators
The asthma register (4 points) is now for patients aged six years and over at the end of March – in line with NICE guidance aimed at recognising the uncertainty of diagnosis in younger children.
It is still the case that patients without a prescription for an inhaler during the QOF year will be removed from the asthma register, but return immediately if they are prescribed an inhaler.
The diagnostic tests indicator has been changed considerably.
Firstly, it has been reset so that it will only apply to patients diagnosed after 1 April 2020. The effect of this is that payment per patient is likely to be very high this year, with 15 points available for a relatively small number of patients. This will fall in future years, however, as more patients are diagnosed and so the payment is diluted.
Secondly, there is now a ‘cliff edge’ to this indicator. Previously diagnostic tests could be performed three months before or any time after the diagnosis. That time after the diagnosis has now been dropped to six months. A patient diagnosed on 1 April must now have had these tests by the end of September or they will count against this indicator forever (or at least until the indicator is changed again).
Thirdly, patients must also have two positive confirmatory tests – spirometry and one other objective test – to be diagnosed and included on the register. The previous indicator required only a measurement of reversibility or variability. The option of FeNO as an alternative is of questionable significance as this test is somewhat mythical in primary care. Given the requirement of spirometry in every case, I would suggest that a handheld spirometer would be a better investment than a FeNO machine. Some CCGs may want to commission FeNO as a local enhanced service and, given the high cost of equipment, this could be delivered by a network of practice.
Finally, there is a system to deal with asthma patients who come to the practice without previous spirometry or diagnostic tests. If they have been diagnosed after April 2020 their six-month window for diagnostic tests will start from the date of registration. This will go some way to mitigate against patients where records of spirometry are unavailable such as when patients come from abroad.
A useful approach to would be to only diagnose a patient with asthma after the diagnostic tests had been completed. Patients who are diagnosed in secondary care or by another practice are more difficult – set up a search that you can run weekly to identify newly diagnosed or registered patients who have a coded asthma diagnosis but no testing.
There is an anomaly in the rules if a patient already has an asthma diagnosis at the time that they turn six years old. NICE recommends spirometry and additional testing at age five although this is not yet reflected.
The asthma review (20 points) has been formalised and structured. It now requires:
It will certainly be worth hitting the ground running with these. Update templates as soon as possible and consider that you may need to offer longer appointments for this. Asthma UK has written asthma plans that are free to download.
The two asthma control questionnaires mentioned by NICE are the Asthma Control Test and the Asthma Control Questionnaire, although, strictly speaking, neither seems to be licenced for general practice use.
Finally the indicator for smoking in teenagers with asthma has been updated to include second hand, or passive, smoking. While the wording isn’t very clear and there is no definition for what exactly counts for second-hand exposure from NICE, this offers a little more flexibility in practice.
Changes to COPD indicators
With the inconsistency for which the QOF is rightly renowned, the revisions to COPD indicators take a different approach to those in the asthma area, despite similar aims.
In this case, the register and the diagnostics indicator have been merged.
The effect of this is that missing the spirometry targets will impact on prevalence rather than point scores. The register is worded as requiring the patient has:
There is the same six-month cliff edge after diagnosis as with asthma. However, in this case, it will not be rigidly enforced, despite the current wording. There is very strong encouragement for patients to have confirmation with spirometry and practices could make this a pre-requirement for diagnosis in most cases.
Patients should be identified when they are registered with the practice and prior diagnostic tests documented.
The spirometry is required to be quality assured. I would suggest that familiarity with the quality assurance guidelines for everyone measuring spirometry would be a good start. Investment in spirometry training and equipment is likely to benefit other COPD and asthma QOF performance.
There are also small changes to the COPD review. There should now be an assessment of the number of exacerbations in the last year recorded, alongside the existing requirement for the MRC dyspnoea scale. Update your templates now to include this.
The wording requiring this to be done by a healthcare professional has been removed, although I am not sure how much to read into that.
Changes to Heart Failure indicators
As with asthma and COPD, the timescale for having a specialist assessment or echocardiogram after the diagnosis of heart failure has been reduced from twelve to six months. At the same time patients can now have the investigation within six months of registering with the practice, if this has not happened before.
There are other changes to the heart failure indicators relating to patients with left ventricular systolic dysfunction (LVSD). These indicators are quite well rewarded on a per-patient basis.
Previously there was one indicator for patients being treated with ACE inhibitors (or angiotensin receptor blockers [ARBs]) and, if they passed that indicator another about additional beta blocker prescribing.
The link between these has now been removed and so all patients with LVSD will qualify for both medication indicators – so practices are awarded points separately for prescribing beta blockers, irrespective of ACE inhibitor/ARB prescription.
It is likely that QOF will require more of your patients to be prescribed beta blockers after this change. Finding these patients early will make things simpler later in the year. Seven points have been removed from the LVSD indicators and assigned to a new heart failure indicator. Thresholds have also been changed for these indicators, although past results suggest that this will not have a large effect on practices.
The seven points that have been removed go to a completely new indicator for an annual review which applies to all patients with heart failure and not just those with LVSD. This must include a functional assessment on the New York Heart Association (NYHA) scale. Medication should also be at the maximum tolerated dose, although this does not require a specific code.
Once again it is important that templates are updated so that the NYHA assessment is made for every patient with heart failure from the very start of the year.
New non-diabetic hyperglycaemia indicator
Non-diabetic hyperglycaemia is defined by NICE as an HbA1c level between 42-47 mmol/mol or fasting plasma glucose between 5.5-6.9 mmol/l. The requirement is for all patients with non-diabetic hyperglycaemia to have an annual repeat of their blood test – either HbA1c or a fasting plasma glucose.
Patients will need to have non-diabetic hyperglycaemia coded separately to the blood test in order to qualify for this indicator. Adding this diagnosis will increase the prevalence figures, and therefore payment.
As a new area to QOF there are few decent figures regarding how many patients will be affected. The numbers we do have suggest that the register for each practice will be 50-100% the size of the diabetes register.
Based on that figure, and assuming a normal prevalence adjustment, I would estimate that this will be worth about £7.50 and £15 per patient. There is also the chance to increase your diabetes register size depending on how many patients end up with a diagnosis depending on the annual blood test results.
These are the same patients you will likely be inviting for the diabetes prevention programme so many of the searches should already be in place. As there could be quite a large number of people to test, it may be worth sending invitations in batches soon as is practical.
Quality Improvement
The QI indicators are to be replaced each year. There are still four indicators – two for each topic area. Three topics have a similar split to last year as week with cancer prevention being more data driven and learning disabilities having softer audit requirements.
Once again it will be for practices to set their own targets for the year based on their own initial findings.
Summary to-do list
These are the key things you need to start doing:
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