With the news that QOF will be reinstated in full from 1^st April 2021, what do you really need to know about the changes to QOF?

QOF for 2021/22 will consist of 635 points, made up of:

The value of a QOF point for 21/22 is £201.16.

Don’t forget that the value of a QOF point is adjusted for your practice list size and prevalence.

You can see your 19/20 QOF performance here, including exception coding.

Points to note

• Significant changes to Serious Mental Illness domain
• New Vaccination and Immunisation domain
• Flu vaccines funding removed and redistributed to IIF
• Indicators with timed features
• HF005, AST006, COPD008 and DM014 all have timed care adjustments for service unavailable
• You need to ensure that indicators with timed referrals or personalised care adjustments are dealt with quickly. Check timed referrals and timed care adjustments, e.g. spirometry, echocardiogram, structured education programme, vaccination and immunisation.
• You may need to consider your policy/protocol for childhood immunisations, to reflect the impact of non-attendance or refusal to engage, including any relevant safeguarding concerns.
• Vaccination lower thresholds are 87% to 90% for childhood immunisations; you should immediately look at the birthdates of your target cohorts for all vaccination and immunisation indicators as there are very limited opportunities for personalised care adjustments within these indicators (8 months, 18 months and 5 years of age). If you do not take immediate action, you may find that you miss the target for the year. Contract documentation also indicates that there will be a partial repayment of the IoS fee for practices who do not achieve a minimum of 80%* vaccination (repayment shown as IoS fee x 50% of eligible cohort size). For practices that do not meet the 80%* vaccination threshold, you should ensure that you are meeting the Core Standards set out in the Vaccines and Immunisations guidance (see references). You can check your uptake on the NHS Digital website (see references section).

Clarification in payments with thanks to the Wessex LMCs

The finance associated with flu vaccines has been moved into the Investment and Impact Fund. This might affect the way that you choose to deliver your flu campaigns this year. As you’ll already have your vaccine order placed, you might want to think about the logistics of this sooner rather than later. For practices where the PCN delivery of COVID vaccines has gone well, you might feel reasonably comfortable. If you opted out of the PCN COVID-19 DES, or you found the delivery of the COVID vaccines very challenging, you might feel quite concerned about this.

With the addition of the Vaccines and Immunisations domain, a significant number of QOF points (64 in total) have been invested in targeting practices at improving uptake of childhood immunisations and the shingles vaccine. While practices have been aware that changes were coming, the now agreed £10.06 item of service fee, with a penalty for those who do not achieve the 80%* threshold, will be punitive for some. This changed pattern of funding for vaccinations shows a real drive to improve nationwide uptake.

We’ve looked in more detail at the significant changes so you’re prepared for the year ahead.

Clinical domains total 401 points.

Heart Failure

Note the change of terminology: ‘reduced ejection fraction usually defined as LVSD’. If you have patients with coded reduced ejection fraction but not LVSD, they may appear in the denominator population this year, or you may need to code them appropriately if that isn’t currently the case.

Asthma

Patients who are over 17 have specific criteria related to objective tests for diagnosis. For patients under 17, or those who cannot complete the specified tests, objective tests are still required, though this may be a combination of alternatives. You may need to refer onwards to achieve appropriate testing. Exacerbations and the asthma control questionnaire or test can be completed up to one month before the review, but the personalised asthma plan needs to be recorded on the same day as the review.

Diabetes

From the start of 21/22, there will be a phased roll-out of the Healthy Living in Diabetes Programme (HeLP); this will meet the criteria for referral to a structured education programme, and referral must take place within nine months (279 days) of entry onto the register. (See also personalised care adjustments.)

Mental health

There are three new indicators in the Mental Health domain. The text of the full QOF guidance suggests using the Lester Tool to complete a mental health physical review. This needs to include a comprehensive care plan, BMI, blood pressure, alcohol consumption, lipid profile, as appropriate, and blood glucose or HbA1c along with other information and tests.

Practices may code the records of those diagnosed with serious mental health conditions as in remission, where this is appropriate.

In order to be considered for coding as in remission, the patient must have had no mental health in-patient admissions, no antipsychotic medications and no secondary or mental health follow-up for at least five years. Even if the patient meets these criteria, it is a significant clinical judgement, and should only be undertaken with the benefit of a protocol to guide the decision-making process. The decision to code a patient as in remission should be made by a clinician.

Patients who have been coded as in remission will remain on the register, but will not appear in the denominators for the subsequent indicators. Any relapse MUST be coded and the patient will then be included in the denominators for the subsequent indicators. Commissioners can request information about the reasons and decision-making for coding a patient as in remission.

Patients with severe mental illness should have a primary care consultation that covers plans for their care in the event that they relapse. This may include the views of their relatives. Where patients have had a relapse after being coded as in remission, their care plan must be updated to qualify for QOF.

Cancer care

Patients will need to have a Cancer Care review using a structured review template (Macmillan’s CCR template) within 12 months of the date of diagnosis; this covers patients who have been diagnosed within the last 24 months. Macmillan also offer information about how to conduct a review and useful information for the patient on their website. Patients who are diagnosed with cancer should be offered the opportunity to have a discussion and be told about the support they can expect from primary care. This should occur within three months of diagnosis and will apply to anyone diagnosed within the last 12 months.

Vaccination and immunisation

There are four new indicators in this domain. Three relate to childhood immunisations along with one that relates to shingles in those aged 70 to 80. Along with a move towards an Item of Service (IoS) model for the vaccinations, this is a significant shift. Each of the childhood immunisations indicators is worth 18 points, so there is a significant amount of money attached, depending on the size and demographic of your practice population. The lower thresholds are set at 87 to 90% with the upper thresholds at 95%, so there is a narrow band for achievement, with between 3 and 7 points for achievement of the lower thresholds.

The indicators relate to:

Childhood imms

Babies who became 8 months in the last 12 months, who’ve had three doses of Diphtheria, Tetanus, Pertussis before 8 months of age.

Children who reached 18 months in the last 12 months and who had one dose of Measles, Mumps, Rubella (MMR) between 12 and 18 months of age.

Children reaching 5 in the last 12 months, who’ve had a reinforcing dose of DTaP/IPV and two doses of MMR between 1 and 5 years old.

Given the age criteria, and the changes in finance, you should immediately look at the children who are likely to miss that target if not called in early, as you could miss your thresholds by low achievement early in the year, even if later in the year you have very good uptake. Those who turn 8 months, 18 months and 5 years in the first couple of months of the QOF year should be checked.

Personalised care adjustments will only be allowed in the event of contraindication. Third invitations should be done via telephone or face to face with a healthcare professional, if the child has not been vaccinated.

In particular, practices with low uptake of vaccination may find this a significant challenge. If you are a practice with a population where ethical or religious beliefs affect your vaccination uptake, you might want to consider whether local religious leaders might be happy to support you, or whether their national or international leaders have issued guidance on this subject. Where parents refuse to engage, or there are DNA appointments, you may need to consider whether your policy should include your safeguarding lead and clinical input, as the guidance indicates that clinical input with the parent or carer should be given.

Shingles

Patients who turned 80 in the last 12 months who received a shingles vaccine between 70 and 79 years of age.

This is worth 10 QOF points with thresholds of 50% (lower) to 60% (upper). There is no point allocation for meeting the lower threshold. Again, you should immediately look at patients turning 80 in the next few weeks. As the target thresholds are lower and the ability to dissent is more likely to be an issue, you may find it’s not as difficult to achieve as the childhood imms targets.

Quality improvement

The Quality Improvement domains this year are related to early cancer diagnosis and learning disabilities. In both cases, practices will be required to demonstrate that they are carrying out continuous improvement activity as specified in the QOF guidance, and that they are carrying out network activity to share and discuss learning. This should include attending a minimum of two network peer review meetings per year.

Practices will need to evaluate their current position in line with the QOF guidance; they will then need to create an improvement plan and implement that plan.  Practices will need to engage with learning and peer review at network level a minimum of twice each year. There will be a Quality Improvement monitoring template to be completed. Targets should be ‘SMART’ and across a range of measures designed to attain continuous improvement.

Personalised care adjustments

Personalised care adjustments will be applied in a hierarchy; this ranks patient choice and clinical judgement above time constraints and non-responsiveness. Patients should have all reasons for adjustment detailed. This enables more robust conversations around healthcare, not just with the patient and other healthcare professionals but with commissioners and regulators too.

HF005, AST006, COPD008 and DM014 all have timed care adjustments for service unavailable; it is vital that any care adjustment necessary is added within the time window required.

As discussed above, the only suitable personalised care adjustment for vaccination will be related to contraindications for children, and related to contraindication or patient dissent for shingles.

We have a blog and policy [PLUS] on personalised care adjustments that you might find useful.

In summary

The major changes are related to vaccination, cancer care and serious mental illness. You need to be very aware of the inability to make personalised care adjustments for vaccination in the majority of cases. There are time-sensitive indicators, and you should look at these as soon as possible, as once the timed intervention has been missed, there’s little you can do about it.

* The Contract guidance paragraph 5.15 refers to a minimum of 79% coverage.  However, NHSE has confirmed that they expect that this will be a minimum of 80% coverage.

Reference documents

Quality and Outcomes Framework Guidance for 2021/2022

Update to the GP Contract Agreement 2021/2022

GP Contract Agreement 2021/2022

Childhood vaccination coverage statistics

Update on vaccination and immunisation changes for 2021/2022