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QOF: Additional services

QOF: Additional services


When the current General Medical Services (GMS) contract was introduced in 2004 it was intended to be modular with three tiers of services. The core services would largely be those dealing with those who were, or believed themselves to be, unwell. Enhanced services could be set nationally or locally and be more dynamic parts of the contract. Both of these are now largely working as envisaged.
When the current General Medical Services (GMS) contract was introduced in 2004 it was intended to be modular with three tiers of services. The core services would largely be those dealing with those who were, or believed themselves to be, unwell. Enhanced services could be set nationally or locally and be more dynamic parts of the contract. Both of these are now largely working as envisaged.

Additional services lay somewhere in between. These were areas that had previously been part of the GMS contract but could be shed by practices which were having problems with workload. These included sexual health, immunisations, cervical cytology (smears), child health surveillance and maternity services. Withdrawal from any of these would lose the practice part of its global sum – eg, 1.1% for cervical cytology and 2.4% for sexual health services.

In reality there have been very few practices that have taken advantage of these flexibilities and they have largely been forgotten. However they still remain relevant as in addition to the global sum payment some incentive payments were also associated with these areas. The immunisation target system remained largely unchanged but for the other areas a separate additional services domain was added to the Quality and Outcomes Framework (QOF).

Cervical cytology counts for half of the points available in the additional services domain. There is a single achievement indicator worth 11 points and three organisational indicators worth another 11 in total. When calculating profitability of cytology it should be remembered that, while in general participation in the QOF is optional, withdrawal from this section would also cost a little over 1% of your global sum.

New for this year is an additional cytology indicator in the mental health area which is worth a further five points. This latter indicator operates in the same way as the normal cervical screening indicator but only for women with a history of bipolar or psychotic disorder. The payment for each smear taken from a patient on the mental health register is therefore much larger than for other women – probably around 100 times greater. These achievement indicators are staged in the same way as clinical indicators with a maximum threshold of 80%.

The achievement indicator is unusual in QOF in that it looks back over five years for female patients who have had a smear test. It is relatively unsophisticated it only looks for a single smear in that time, even if the patients is recommended to have more frequent testing – for instance, if one result was borderline. It also does not take into account pregnancy which may justifiably delay a smear test.

The age range for this indicator also varies across the four countries of the UK. Women between 25 and 64 at the end of the QOF year are included for practices in England and Northern Ireland. In Wales they would count from 20 years old and in Scotland the range is 20-60. Welsh practices may observe unhappily that they will have to do more screening for the same number of points.

There are two main reasons for exception reporting in this indicator. Fairly obviously, women who have has a hysterectomy with complete removal of the cervix do not normally require to have a smear test. Coding should be carefully checked not only to improve the recording for QOF purposes but to prevent avoidable distress by sending out an invitation to women who have had their cervix removed. The Read codes in this area are not well designed and code synonyms should be avoided (particularly 7E045) as they may have misleading text. These are, naturally, enduring exception codes that do not need to be repeated.

In some cases, normally where the hysterectomy was performed for malignancy, women are recommended to have vaginal vault smears as part of the follow up. This is not considered part of the routine primary care cytology service and is not counted for this indicator.

The second reason for exception reporting is non attendance for screening. As with most of QOF three reminders should be sent although this only needs to be done once every five years rather than annually. In many areas letters are sent out from a centrally organised screening services. This year letters from a central service can count for the first two of these reminders. The third must still come from the practice itself.

Of course three letters are only required where there is no response from the patient. Where the patient tells the practice, preferably in writing, that they do not want to have a smear then another letter is not required for a further five years.

The codes for non attendance became a bit more restrictive with version 20, which came out in the summer. Previously codes could be entered for smear dissenter but from this year only the codes stating "not wanted" or "refused" are valid. As the rules look back over five years this is effectively a retrospective change and could cause problems for practices. If you have used one of the old codes you will almost certainly have to go back up to five years and change or add to them. Some of these may have been entered more than four years before the change was announced.

The organisational cytology indicators are pretty straightforward and relate to having protocols for the management of the smear programme and for informing patients of the result. The final indicator is for an annual audit of the adequacy of smears taken in the practice. This should be relatively routine in practices and be no more complex than a register of the smears taken and their outcomes. There should be an effective mechanism visible to the PCT at the time of a QOF assessment.
The sexual health indicators were previously known as the contraception area although have changed a little in that transfer. There are three indicators here and all have the same structure as an area in the main clinical domain.

There is a register indicator for female patients who have been prescribed reversible contraception over at least the past year which carries four points. Most of this would be available from the practice prescribing records and is searched for automatically. There is no age limit to this register or requirement that the prescription should have been for contraceptive purposes. Patient having contraceptives for cycle regulation, endometriosis treatment or acne will be included on this register.

Patients who have had contraception elsewhere, for instance at a family planning clinic, should have this coded. This is most likely in the case of contraceptive devices or implants. This will add to your prevalence calculation for the three indicators in this area. Devices and implants are counted within the effective lifetime of the device although only new uses from April 2009 are counted.

The other two indicators are about giving advice about long acting contraception. It is important to be clear to whom this advice should be given. The rules require that all women who have been prescribed an oral contraceptive or a transdermal contraceptive patch in the previous 15 months for whatever reason should have this advice. This applies even if there is subsequent discontinuation of that method of contraception or even subsequent use of a long term reversible method.

The advice should be both verbal and written, although in practice the offer of a leaflet is frequently declined. It is simplest to code this advice with 8CAw although there is the option to give the verbal and written advice separately with 8CAw1 and 8CAw2.

The timing varies between the two indicators. The first indicator refers to women who have had prophylactic contraception and the advice should be given in the 15 months before the end of March. As with many indicators achievement in January, February or March will be counted in two separate QOF years.

For the second indicator, which applies to patients prescribed emergency contraception, the timetable is much tighter. The advice needs to be given within one calendar month of the prescription of the contraception. Most conveniently this is done at the same time as the prescription but can be later. Once again there is no flexibility here and the advice will need to be formally repeated even it was given one day before the emergency contraception prescription.

The usual exception codes for informed dissent and unsuitable patients apply to the sexual health area.

There are two more areas in the additional services domain although there are entirely organisational and there is no automatic data extraction from the practice systems.

The first of these is child health surveillance and the single indicator requires practice to have a system ensuring that this takes place according to national guidelines.

The final section is maternity. Again there is a single indicator which confirms that the practice offers antenatal care and screening in line with local protocols.

The additional service domain tends to appear at the bottom of lists but is worth attention as work in one year can pay of for several years into the future.

Dr Gavin Jamie
Swindon GP and Webmaster of the QOF Database


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