It is easy to slip into hyperbole about the revisions to the QOF from 1 April, but it is certainly the biggest change the framework has seen since its inception.
For English practices, there are four ways in which the QOF has changed:
- there are a whole host of new indicators plus changes to existing ones
- the thresholds for 20 of the existing indicators have gone up – the rest will follow in April 2014
- we now have less time to do all this – down from 15 months to 12 months for many indicators
- almost all of the organisational domain has disappeared.
The fifth big change is that the QOF is now different in England, Scotland, Wales and Northern Ireland.
Wales has in fact kept a chunk of the organisational domain and both the Welsh and Scots have avoided some of the more awkward indicators, but most of the new indicators are common to all of the countries.
The changes make some indicators much more financially lucrative than others and a few simply do not cover the cost of implementation. This article categorises indicators as ‘must-do’ and ‘should-do’ work – and highlights indicators that may not be worth chasing.
Rheumatoid arthritis RA001 to 4 (new)
There is only one new clinical area in the 2013/4 QOF: rheumatoid arthritis. This is mostly an administrative area, requiring an annual review and the risk calculation of cardiovascular disease and osteoporotic fracture. The cardiac risk formula needs the result of an HDL:total cholesterol ratio to be available, so this test should be scheduled early in the year to make sure it happens. Osteoporotic risk should be measured by either the QFracture or FRAX formula.
We don’t have a clear idea of how many patients this will apply to but it is unlikely to be a large number. Eighteen points for this disease area are likely to make it attractive to practices.
Diabetes DM014 (new)
Diabetes targets have always changed more than any other area and this trend is set to continue. The best-paid of the new indicators is the referral of patients newly diagnosed with diabetes to a structured education programme within nine months of their entry in the register.
There are 11 points for this, which is pretty generous for a fairly simple referral, but of course it will be necessary to have a local structured education programme to refer patients to. Exception reporting is likely to apply, but if all patients are excepted the practice will not get any of the points. It is not clear whether practices will get the points for referring to a non-existent service.
CCGs are likely to be under pressure to make the provision of such a service a priority and practices are encouraged to apply more of that pressure.
We do not have the business rules for this indicator yet – it is possible that it could apply to all patients diagnosed since July 2012.
Diabetes mellitus DM015 and 16 (new)
This pair of indicators relates to erectile dysfunction in men over 18 with diabetes. Practices can earn four points for asking about it, in the same way as depression screening, and a further six points for subsequent advice, assessment and consideration of options. Ten points here is probably a reasonable reflection of the time it will take.
Diabetes mellitus DM005 (replaces DM13)
Microalbuminuria in diabetes must now be measured by a urinary albumin:creatinine ratio. Dip testing is no longer sufficient. This brings the QOF in line with the National Diabetes Audit. The related indicator requiring an ACE inhibitor or an ARB in patients with microalbuminuria has been amended in the same way.
Cardiovascular disease – primary prevention PP001 (replaces PP1)
There are changes to the primary prevention indicators too.
In the 2012/13 QOF, all patients newly diagnosed with hypertension had to have a CVD risk calculated for eight points. From this month there will not be any points awarded for this.
The replacement will be an indicator giving 10 points for a statin prescription in those patients who have a calculated 10-year risk of 20% or over. It is not terribly clear from the proposed wording how patients without a score will be dealt with by the business rules. The current wording suggests that only those patients with a coded risk will be considered for this indicator, meaning practices may end up better off if they code fewer patients.
It is more likely this will become a two-stage indicator with both steps being required.
Depression DEP001 and 002 (replace DEP 1 and 6, and 7, respectively)
One of the longest-awaited changes is to the depression indicators. The PHQ-9 and other questionnaires have not been particularly popular and lacked a clear evidence base. These have been replaced with what is described as a bio-psychosocial assessment before making the diagnosis and a review between 10 and 35 days afterwards. The points available have been increased this year to 21 for the first assessment and 10 for the review.
The initial assessment is mostly the same sort of history and mental state examination that GPs have been carrying out for years. There are 11 compulsory areas which should be considered part of the assessment, such as past history and current living conditions. It is not clear how this will be coded – will each part of the history require a code or will a single code be adequate? Again we await more details.
Lastly, note that the indicator for screening for depression with two questions in patients with diabetes or heart disease has been withdrawn.
Indicators to drop?
In my view, the income from the following indicators is probably not worth the work they take.
Diabetes mellitus DM013 (new)
Rather less lucrative are the three points offered for annual dietary review in every patient with diabetes. The indicator states that this should be performed by ‘a suitably competent professional’. In Scotland this has been confirmed as including a GP without any further training – but, in England, training to level one of the Diabetes UK competency framework for dieticians is needed (download this at tinyurl.com/diabetic-framework). With only three points on offer, this indicator will pay for less than five minutes of practice nurse time, so it is unlikely to be financially worthwhile for practices.
Hypertension HYP004 and 005 (new)
Two indicators that apply only to England and possibly Northern Ireland are about exercise in patients with hypertension. Hypertension has the highest prevalence of any clinical area – nearly 14% in England. There are two indicators, both with a rather miserly three points.
The first is for completion of a GPPAQ questionnaire in all hypertensive patients aged 16–74. GPPAQ is fiddly to score and is certainly more work than the depression screening questions.
All patients who are found to be ‘less than active’ will require a brief intervention. Given that the points are likely to pay for less than two minutes of practice nurse time this would have to be a very brief intervention indeed to make it financially worthwhile for practices.
There are other, more minor, changes too.
Hypertension HYP003 (new)
The target for blood pressure in hypertension has been split for practices in England, Wales and Northern Ireland. There are 10 points for the old target of 150/90 in all patients with hypertension, but over 45 points are available for a new, lower, target of 140/90 in patients under 80 years old. It is likely to be quite a challenge for practices to get to the 80% required.
Although the organisational domain has been removed, some of its more clinically relevant indicators have been preserved.
Blood pressure BP002 (new)
Since the start of the QOF there have been two indicators (Records 11 and 17) in the records area about the measurement of blood pressure in patients aged 45 and over. This was simply about taking the reading and there were five points for 65% of patients and another 10 for getting to 80%. With the demise of the organisational domain, these have been saved. Unsurprisingly, it is tougher to get the points – the age range has been widened to the over-40s and practices must now get to 90% to earn all 15 points (the threshold will be raised more gradually in Scotland). At least now it runs like a normal clinical indicator, with a smooth increase in points from 50% upwards.
Dr Gavin Jamie is a GP in Swindon who runs the QOF Database website
The full version of this article is available as a CPD module, worth a suggested 1 CPD hour. It includes the new thresholds and advice on coping with the new 12-month QOF period.