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Five key questions on managing QOF finance

Caroline Kerby takes five key questions, from VAT to under-achieving indicators.

What steps should you take in assessing whether a particular aspect of QOF is financially viable?

Most practices during the last two quarters of the year will be working through the clinical and organisational domains to ensure the coding of the clinical input is accurate, and achievement is maximised through careful management of outstanding items of care.     

This process of reviewing the performance of each indicator includes assessment of the low-hanging fruit where a minimum input will achieve maximum QOF points.

For example, in mental health you could check the lithium level of one patient for one QOF point, or check the BMI of 19 patients for half a point. Both are valid as good clinical practice but the work required to achieve the desired outcome varies significantly.   

Are there areas where achievement on QOF can arise as a by-product of what you're doing elsewhere in the practice?

QOF should not be seen as an additional aspect of what the practice does: the indicators look to evidence-based practice and I always advise practice managers that if you provide good comprehensive clinical care, QOF is no more than a data challenge.    

First, look for areas where you can increase productivity. In our team, people lead on specific indicators – for example, the phlebotomist follows Thyroid 2 and recalls patients for their thyroid function tests on a routine basis. The drug-monitoring facility in our clinical systems, whilst not directly linked to QOF, is used through the repeat prescribing process to ensure that appropriate monitoring takes place. We have also found the NHS Health Checks to be a rich source of QOF-related data on patients who often do not visit the practice and continues to increase our achievement of the Records 23 indicator.

Patients lead busy lives and appreciate ‘one stop' style services.   We try to ensure that they are not asked to attend repeat appointments, but insofar as much as possible we try to make sure that the correct data has been captured.

Are there any cases where taking the QOF point are not financially justifiable, and how would a practice determine this?

As mentioned earlier, it has been a challenge for my practice to achieve Records 23, smoking status in the over-15s. We have achieved 81% of the 90% target but we would need to verify the status of 1,271 patients for one and a half QOF points.

We have increased our achievement over the previous years but the cost of contacting 1,271 patients vastly outweighs the income that would be generated from one and a half QOF points.

The practice QOF plan needs to maintain achievement by a constant coding vigilance - recording necessary data on new patients, newly diagnosed patients and the management of existing patients. As the thresholds for QOF increase, each target will become more challenging and the balance between the work required and the achievement gained will become even more focussed for practices.

How can a practice claim against VAT for any new investment they have put in place for QOF?

Some practices are now required to register for VAT if their private income exceeds £73,000 per annum. It is possible to register voluntarily and it is worth discussing with your accountant if there are any advantages to your practice in terms of the ability to reclaim VAT.

The administration of VAT registration is considerable and needs to be carefully considered. A monthly return will need to be made, which increases costs for both book-keeping and accounting. You may also wish to insure against any subsequent investigation.

If your practice is considering a premises development or refurbishment it is worth discussing with your accountants but, as with additional QOF points, you need to balance out the cost and the benefit. For more information the HMRC website is your best source of information.

How can a practice ensure they don't get caught by the need for payback if their achievement is less than the indicative payment?

A key aspect of QOF is to ensure that you are recording accurate prevalence, as this will have an impact on the value of each QOF point generated. One way to do this is through comparing benchmarked comparator data: if your PCT or practice appears low, ask why. It is always worth validating the practice register through drug searches but also through reviewing non-elective (emergency) admissions for long-term conditions.

A recent local comparison of asthma registers against emergency admission data suggests that the true prevalence is much higher that current reported. Most PCTs can supply patient identifiable information by ICD10 diagnostic codes, which can then be compared to the practice register.

The next aspect would be to monitor QOF on a regular basis so there are no nasty shocks.  This is a marathon, not a sprint.

The practice should be made aware of their achievement as they progress through the year, multiplied by the value of a QOF point compared to the aspiration income received.

In the sentiments of Charles Dickens' Mr Micawber, ‘annual QOF aspiration 850 points, annual QOF achievement 950 points, result: happiness.  Annual QOF aspiration 950 points, annual QOF achievement 850 points, result: misery'.

QOF is an important source of practice income and every practice needs to be extra prudent in these turbulent times.

Caroline Kerby is managing partner at Brentfield Medical Centre in Brent, London, and clinical lead of the Harness Commissioning Group

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