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How to maximise your QOF income

Close scrutiny of QOF data can help practices earn more points for the year, says Dr Jeremy Phipps.

QOF indicators: much of your evaluation of QOF work revolves around ensuring the right information is correctly coded (Photograph: SPL)
QOF indicators: much of your evaluation of QOF work revolves around ensuring the right information is correctly coded (Photograph: SPL)

As 31 March, the end of the QOF year, approaches, most practices are working hard to ensure a high score for this year and making preparations for 2012/13.

Most of the QOF reflects good clinical practice, so much of the work revolves around ensuring the right information is correctly coded.

The QOF is often criticised as a box-ticking exercise and although this is possibly the case with some small parts, most of it, especially in the clinical domains, is purely rationalising the already high standards of care in general practice.

Clinical registers
Although the QOF has been in place for seven years, it is worth revisiting the basics and, in particular, checking whether the disease registers are correct.

For example, it may be the case that some patients on your IHD register who have not had their cholesterol checked are distorting your figures if they have been entered in error.

This often occurs with A&E discharge letters when a provisional diagnosis of MI following investigation turns out to be incorrect.

The converse may also be true for patients who have been receiving excellent care for their illness, but may not have been correctly coded, so will not be included in any QOF claims.

Checking registers by, for example, completing simple medication searches for patients on thyroxine or diabetic medication, may identify some missed patients.

Producing accurate disease registers helps the practice but because they are usually the basis for recall of patients for review, accuracy supports good clinical care.

Exemption coding
Despite all the accusations of widespread manipulation of the QOF by practices through potentially fraudulent use of exemption codes, all independent research has confirmed this to be far from true.

This last quarter of the NHS year is a good time to complete any relevant exemption codes because doing this will usually cover two separate QOF qualifying years and reduce the need for work duplication.

Exemption codes will always be needed on occasion. For example, it is not always possible for me to conduct depression screening on a patient with severe learning difficulties who also has heart disease.

Nor is it appropriate to try to arrange a series of diabetic monitoring bloods on a palliative care patient.


Quality prescribing indicators
These have been removed after only a year.

A&E attendance
New indicators relating to this are extremely controversial, given that the latest research questions the role of primary care in influencing patients' A&E attendances.

As is often the case where secondary care is involved, data quality will be a great area of concern. Time and again, hospital attendance figures are shown to have gross inaccuracies. Possibly the greatest influence is how close a patient lives to an A&E department.

Peripheral arterial disease
This new domain relates to well-researched and clearly defined clinical targets. The initial task is compiling a register. The Read codes for this register have yet to be released. When they are available, check that all relevant patients have been included.

Currently there is no Read code for peripheral arterial disease and it is possible that the one for peripheral vascular disease will be used instead. Beyond this main diagnosis, it is unclear which other codes will be used in the register, or whether patients with intermittent claudication or who have undergone relevant surgical procedures, including femoral-popliteal bypass, will be automatically included.

The remaining parts of the domain are to ensure patients have their BP and cholesterol monitored and the use of aspirin or similar medication is recorded. Recall mechanisms may be a problem for peripheral arterial disease patients not on any prescribed medication because calling patients for medication reviews is usually the simplest monitoring method.

This may be particularly so for patients aged under 60 who buy their low-dose aspirin OTC.

Most patients are likely to be included in other domains - especially IHD and diabetes - and the monitoring for these will also cover that required for peripheral arterial disease.

This new domain is really bringing into QOF what was previously an enhanced service but it will only include patients with fragility fractures occurring from 1 April.

A main concern with the osteoporosis DES revolved around populating the register, remembering to add the fragility fracture code to those who should be included. This is likely to remain a problem.

A new indicator in this domain requires calculating and entering a CHADS2 risk code.

CHADS2 scores relate to the risk of a future cerebrovascular accident and are the sum of a history of medical problems, such as diabetes, along with the patient's age. Administrative staff can complete the CHADS2 outside a normal consultation.

Potential gains
Although we try to have a rolling programme of clinical care for our patients with long-term conditions, there are a few areas left to the year end that are worth looking at now.

Many practices may have already hit their flu targets but we usually have to chase up the last few patients early in the calendar year and ensure we record those who decline the immunisation. Again this is an area where QOF targets and good clinical practice coincide.

Other areas are left to the last minute due to the indicator's nature. This occurs with monitoring lithium as this has to be repeated every three months.

At this stage it is unlikely that significant inroads can be made into an indicator with a large denominator, such as the overall smoking rates for the practice. But other areas involve a handful of patients and with a little work, you can increase the point score relatively easily.

Practice IT systems have programs demonstrating QOF achievement in a dynamic fashion (population manager in the EMIS system is an example). These may also predict future attainment by 31 March and so aid practice efforts to target specific areas for points gain.

This extra effort is often fruitful in areas introduced only recently and affecting relatively few patients: for example, the thyroid checks in patients with Down's syndrome and cardiological referral for all new patients with IHD. The latter in particular may be missed due to inadequate coding. Patients may have been seen for their angiograms at outpatient cardiology clinics but the correct code has not been added. This may be done retrospectively.

Organisational indicators
GPs often concentrate on the clinical domains but points may be lost from inadequate completion of these usually administrative tasks. There is a sense that organisational indicators are less important, in part due to them being based on less robust evidence.

They do however contribute significantly to the overall QOF points score. It will be frustrating if your practice's score is reduced purely because you have not organised or recorded a meeting on significant events or completed the audit on clinical indications for medicines prescribed.

There is still time for practices to organise clinical meetings or audits required for compiling the QOF annual return. As well as benefiting the overall points scored, they can be used in your GP appraisal folder.

It is helpful to go through the list of these indicators at this stage in the year with the practice manager and possibly the senior nurse to ensure that all those applicable areas have been completed and adequately recorded. This will also facilitate and simplify any post-verification checks on the practice's QOF achievement.

Most practices have developed a routine for establishing a good QOF score reflecting their clinical practice. While at times we may moan about the few areas such as repeating depression scores that seem less relevant to general practice, most GPs believe it has improved the clinical care of patients as well as providing a financial return.

  • Dr Phipps is a GP in Lincolnshire.

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