What the QOF changes will mean for GP practices

Dr Gavin Jamie, a GP partner in Swindon who runs the QOF Database website, unpicks what the GP contract says about changes to the QOF as well as childhood immunisations

1. QOF

NHS England: ‘QOF will be streamlined in 2023/24 by income protecting all register indicators. This will release £97m of funding and reduce the number of indicators in QOF from 74 to 55 (a reduction of 25%). Funding will be paid to practices based on 2022/23 performance monthly once the 2022/23 QOF outturn is finalised.’

Dr Jamie: ‘The QOF register indicators likely refer to those that require a register of patients to be held, such as with epilepsy, heart failure and chronic kidney disease. I estimate that there are around 19 of these, which will be income protected. I think this income protection element is the biggest change to QOF, but without any details, it’s confusing.

‘NHS England said that money will be “released” but that is generally their code for “not paid to practices”, and there is quite a bit of money involved. This change may also signal a transition to none of the register indicators having points, but the timescales are not clear.’ 

NHS England: ‘Two new cholesterol indicators (worth 30 points~£36m) will be added to QOF along with a new overarching mental health indicator. These will be funded by retiring indicator RA002 (the percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months) and reducing the value of DEM004 (annual dementia review). The mode of review of DEM004 will also be amended to be determined through shared decision making with the patient.’

Dr Jamie: ‘The addition of an “overarching” mental health indicator may pose problems. As a general rule, big “overarching” indicators are a complicated mess. Several simpler ones tend to be easier to manage. Cholesterol indicators have been part of QOF and we await the details to see how these differ this time.

‘The two things that I would watch out for here are inclisiran (is it contractual now?) and QRISK (could make things tricky for EMIS practices?).’

NHS England: ‘Indicator AF007 will be retired and replaced with the indicator below (which was in the IIF as CVD-05 in 2022/23).

‘AF008: Percentage of patients on the QOF Atrial Fibrillation register and with a CHA2DS2- VASc score of 2 or more, who were prescribed a direct-acting oral anticoagulant (DOAC), or, where a DOAC was declined or clinically unsuitable, a Vitamin K antagonist (12 points, LT 70%, UT 95%).’

Dr Jamie: ‘The retiring of Atrial Fibrillation Indicator AF007, and the inclusion of a similar indicator taken from the IIF, seems sensible. They had different criteria before and this is now consistent.’

NHS England: ‘There will also be a number of other small changes to indicator wordings and values in 2023/24.’

Dr Jamie: ‘My breath is baited.’

NHS England: ‘The QOF QI modules in 2023/24 will focus on: workforce and wellbeing; optimisation of demand and capacity management in general practice.’

Dr Jamie: ‘I went to see the film Cocaine Bear last week. It was very clear from the title what was going to be involved. The same is not true of the QI modules here – “workforce and wellbeing” could be anything from appraisal to yoga.’

NHS England: ‘Work will need to be undertaken during 2023/24 to review QOF in its current form with the aim of making it more streamlined and focussed. The profession, patients and the broader system will be consulted to determine the most appropriate form in 2024/25.’

Dr Jamie: ‘This is meaningless waffle. Would it ever be feasible that they were not doing this?’

2. Childhood immunisations

NHS England: The following changes will be made to childhood vaccinations: the removal of the V & I repayment mechanism, removing the payment clawback for practice performance below 80% coverage across the routine childhood programmes; changes to the childhood V & I QOF indicators; clarification of the wording in the SFE that an Item of Service (IoS) fee will be payable for vaccinations administered for medical reasons and incomplete or unknown vaccination status (evergreen offer) for the 8 programmes outlined in the SFE Part 5 Vaccinations and Immunisation, section 19.

Dr Jamie: ‘Removing the clawback – this is good.’

NHS England: ‘The changes to the childhood vaccination and immunisation indicators within QOF will see the lower thresholds reduced to 89% (VI001) 86% (VI002) and 81% (VI003) and the upper thresholds raised to 96%1 . All the points for each indicator will be put into a sliding scale of reward between the lower and upper threshold. Reducing the lower thresholds will decrease the number of practices receiving no payment across the three indicators.’

Dr Jamie: ‘These changes are probably sensible and avoid the cliff edges. I have not run the figures, but on the whole, I think that practices might have fewer points due to the removal of the lump of points at the lower threshold and the higher top threshold. That is likely to vary quite a bit between practices, too.

‘There will be winners and losers. For example VI001 practices with achievement in the low 90% will lose out as there will not be a block of points at 90% and practices at 95% will lose because of the upper threshold change. Obviously other practices will gain. Similar weirdness in other VI indicators.’

NHS England: ‘A new Personalised Care Adjustment will also be introduced for patients who registered at the practice too late (either too late in age, or too late in the financial year) to be vaccinated in accordance with the UK national schedule (or, where they differ, the requirements of the relevant QOF indicator).’

Dr Jamie: ‘The fact that children who register late in the year or outside their immunisation window will be exception reported may have a bigger, positive effect on practices. If this had all come in two years ago, we would likely have had a more positive reaction.

‘As usual, we await the fine print.’

Dr Gavin Jamie is a GP, owner of QOF database website, and writer on QOF and GP contractual issues. He is based in Swindon, Wiltshire