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Decoding QOF

Decoding QOF

Insight: QOF
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At last we know how the Quality and Outcomes Framework (QOF) will look next year. The good news is that there are no new clinical areas and the changes to the existing clinical areas are fairly minor. There are big changes, however, in the patient experience domain. Nearly a tenth of the QOF is now devoted to managing prescribing and commissioning budgets, and several clinical indicators have been removed to make way for this.

At last we know how the Quality and Outcomes Framework (QOF) will look next year. The good news is that there are no new clinical areas and the changes to the existing clinical areas are fairly minor. There are big changes, however, in the patient experience domain. Nearly a tenth of the QOF is now devoted to managing prescribing and commissioning budgets, and several clinical indicators have been removed to make way for this.

These budget management indicators are really new. This has 96.5 allocated and seems likely to dominate implementation this year. They have been split into three areas:
1. Prescribing – five indicators worth 28 points
2. Outpatient referrals – three indicators worth 21 points
3. Emergency admissions – three indicators worth 47.5 points

Each area will require a practice review, an external peer review and the practice to follow three pathways. Who these peers will be and what they will be reviewing is still to be announced. Becoming a 'peer' may be a lucrative sideline. These indicators are planned for one year only with a possibility to extend to two years if savings are seen by the middle of this year. This extension would run until the date that consortia are to take over.

From a standing start it seems highly unlikely that savings could be demonstrated by the middle of the year. The infrastructure to review services and subsequently review the effects of changes is simply not up to the job in most areas. It's suspected that a second year will be added simply because there is no evidence of effect in year one.

Most of the indicators removed from the QOF for 2011/12 are process indicators. These are the indicators about the recording of actions rather than a diagnosis or outcome.

[[What's out]]

The biggest clinical changes are in the area of mental health. The mental health annual review indicator has been split into six more detailed areas. All patients on the mental health register now need a record of the amount of alcohol consumed, blood pressure and body mass index in the 15 months before April 2012. They will also require a blood test for glucose and a cholesterol: high-density lipoprotein (HDL) ratio – not simply a total cholesterol. A further indicator rewards cervical screening in appropriate patients.

More minor changes in mental health include more restricted timescales for blood tests in patients taking lithium. The creatinine and Thyroid-Stimulating Hormone (TSH) must now be measured after 1 July and the lithium level must be in the therapeutic range after the beginning of December. This is pretty tight, particularly if any of the patients have results outside the range and need dose changes and repeat tests. It may be prudent to do all tests in December to allow time for retesting before April.

All patients with Down's syndrome who are over 18 years old will need a TSH measurement annually. Beware of small numbers here. A typical practice will have around five patients with Down's – three of them over 18. Each patient would be worth a point. It is likely that some practices may have no eligible patients and will miss out on these three points entirely. Although the upper threshold is 70% for small and medium practices with only a couple of patients each may be worth over 30% – so you will need them all to get the full three points.

Depression also has some minor changes. The depression screening indicator, requiring two questions to be asked of patients with chronic disease, has had two points taken away. The first assessment questionnaire for newly diagnosed depression has lost eight points and had the wording updated a little to bring it a little closer to what the data extraction rules actually say (although it is still by no means an wholly accurate reflection). The second assessment can now be done four weeks after the first, rather than five, but loses 12 points – leaving it with only eight. Its upper threshold has dropped to 80% so it should be a little easier to achieve.

Patients who are newly diagnosed with dementia from this April must have a blood test for full blood count, calcium, glucose, vitamin B12, folate and renal, liver and thyroid function within six months of diagnosis. It is essential that you don't miss this period as once the six months have passed you cannot work to regain the indicator. Success, or failure, in this indicator will carry on from year to year. It will also be important to ensure these results are coded when patients join the practice in future years.

There is a new indicator in epilepsy offering three points for annual contraception counselling in women under 55. There is presumably a lower age limit but it has not been specified.

The blood pressure targets in diabetes are now tiered. Previously the target was 145/85 for eighteen points. There are now two tiers. The higher, with eight points, is at 150/90 and the lower target of 140/80 has 10 points.

Also in diabetes, the foot pulse assessment has been expanded to require a formal risk classification for foot disease. An extra point has been added for this and the separate foot sensation check indicator (DM10) remains in place.

As was expected, the lowest HbA1c target has been raised from 7% to 7.5% and the wording changed to reflect the move from percentage to mmol/L. The equivalents are listed in table 1.

The biggest change in coronary heart disease (CHD) is an increase in the treatment required for patients with a new heart attack. The current indicator (CHD11) will be expanded to require an ACE inhibitor, aspirin, beta-blocker and statin or suitable alternatives. Patients are included if they have a myocardial infarction from 1 April this year. This is effectively a four-stage indicator and will need at least four codes or prescriptions to get the points, and at least six codes to exception report. To compensate for this complexity there is an increase from seven to 10 points.

Separate indicators for the use of beta-blockers and aspirin in patients with CHD of all sorts and onset dates remain as before.

The requirement to refer patients with a new diagnosis of angina for specialist assessment remains, although the reference to exercise testing has been removed in line with NICE guidance.(1) The same guidance actually suggests that this referral is not required for clinically unequivocal stable angina and so exception reporting is likely to be extensive here. It is vital that at least one patient is referred, though, to ensure that you gain the seven points.

Last, and most certainly least, in the clinical domain is the raising of the upper threshold of blood pressure indicators in CHD, stroke and diabetes from 70% to 71%. This will affect a tiny number of practices to a tiny degree and it is not clear why they bothered. For instance, in CHD there were only two practices whose achievement fell between 70% and 71% last year.

Inline figure

Dr Gavin Jamie
Swindon GP
Webmaster of the
QOF Database

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