Tip 1. Decide what you are doing (or not)
There are many new indicators in the QOF this year. Some of these are simply tightening of current targets and some of them are completely new.
Some of these new indicators are worth considerably more per patient than others. A few of the new indicators, particularly those about exercise assessment in patients with hypertension and dietary review for patients with diabetes, are unlikely to cover their costs. In addition the evidence base is less than robust.
With lower thresholds at forty percent or more there is no point in a half hearted approach as you will likely get few, if any, points. Decide now which indicators you will be attempting and stick to the plan.
Tip 2: Identify weak areas
Thresholds have risen in 20 indicators. Some of the upper thresholds have risen to 100% and most of the others to the high nineties in England. Look at your results for 2012/13. In theory around a quarter of practices will already be achieving these new thresholds. The other three quarters of practices will need to increase their achievement if they want to maintain their income.
Work out now which areas you will need to concentrate on and how you will manage to increase the achievement or possibly by more efficient exception reporting.
Tip 3: Establish strong policies
Until now local prescribing and referral policies have been set by the PCT. The PCT has also been responsible for looking at your QOF data so these things were generally taken together.
From this April in England your CCG will likely set referral and prescribing policies and the NHS Commissioning Board will examine your QOF data. There is potential for disagreement about what would be suitable for exception reporting. Make sure you have clear policies if it all gets messy at the end of next year. Exception reporting will be more important than ever this year.
Tip 4: Start calling patients early
Starting to call patients for review early in the year is especially effective where the timescale for most indicators has reduced from fifteen months to twelve. If patients are not going to attend for review then sending the letters early will make it easier to exception report them later in the year.
Less cynically, calling patients for outcome measures such as blood glucose or cholesterol measurements early in the year will allow the practice to see which patients need further treatment and subsequent retesting during the year. A surprisingly high reading at the end of the year gives no time to correct it.
Tip 5: Aggressive blood pressure management
The blood pressure indicator for patients on the hypertension register has been split this year. The target of 150/90 remains, but now only has 10 points. A new target of 140/90 now has over 45 points, although this latter target only applies to patients under 80 years old at the end of the year.
As before, only blood pressure readings from the first of July will count towards the points in the hypertension area. The earlier that patients who will not meet the new target are identified and have treatment intensified the better.
Tip 6: Do rheumatoid arthritis calculations early
The only new disease area this year is for rheumatoid arthritis. There is a fairly conventional annual review indicator. More unusual are two indicators requiring calculations. Firstly there is an annual cardiovascular risk assessment using the QRisk formula. This will need an annual Total Cholesterol:HDL measurement.
Less familiar to practice will be an annual calculation of bone fracture risk using either the QFracture or FRAX formulae. Both of these require quite a wide range of information, QFracture needing more than FRAX, and ideally these should be integrated into practice computer systems. Practices should decide which to use and start compile a register of patients with rheumatoid arthritis who will need them.
Tip 7: New diabetes indicators
There are two new indicators in diabetes which are quite different to what has been mandated in the past.
The first is for referring patients newly diagnosed with diabetes to a structured educational programme. With 11 points available and not particularly large number of patients this should be within the reach of most practices as long as services are available and accessible.
Where a service is not available exception reporting will help, but if all patients are exception reported then the practice will not get the points. There seems nothing in the rules about the provision of services and so we may end up in the bizarre situation of GPs being paid to refer patients to non-existent services.
All patients with diabetes should have an annual dietary review. This should be a 'suitably competent professional'. In Scotland this can be a GP. In England this must be a dietician or someone who meets level one of the Diabetes UK competency framework for dieticians.
With only three points this is unlikely to be financially viable, particularly if extra training is required.
Tip 8: Start measuring blood oxygen saturation
Patients with COPD stages 3-5 (the same group than will need annual referral for pulmonary rehabilitation, although this indicator has now been deferred until 2014) also require an annual check of blood oxygen saturation. It makes most sense for this to be done at the annual review to establish a baseline of oxygen saturation. It will then become possible to see any changes during exacerbations.
Many doctors already have a suitable device to measure this and the points available will more than cover the cost of buying one.
Tip 9: Get to grips with depression assessment
The questionnaires for the assessment of depression were never particularly popular, but their replacements, while more clinically relevant, are also more complicated. It is important to be aware of these from the start of the year as there are strict timescales for the new assessment.
There are now 21 points for an initial biopsychosocial assessment which must occur before the diagnosis is made rather than after, as in the 2012 QOF. The details of the assessment are lengthy but boil down to a good history and mental state assessment.
There should be a review of the issues identified between 10 and 35days of the date of diagnosis - this will be worth ten points.
Tip 10: Systematically ask about erectile dysfunction
This year there are two indicators about erectile dysfunction in men with diabetes. All male patients on the diabetes register should be asked about problems with erection annually, with a total of four points available.
There is no age limit specified, although only patients over 18 years old at the end of the year are put on the register. As the age is at the end of March 2014 you will need to ask most 17 year olds through the year.
There are a further six points for assessment of exacerbating factors and possible treatments in those patients who report a problem.
- Gavin Jamie is a GP in Swindon and runs the QOF Database website www.gpcontract.co.uk