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Quality time


25 March 2011

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The sight of tinsel in the shops always makes GPs
think of flu jabs, and recently the shelves lined with Easter
eggs will start to remind some health professionals, possibly
the more obsessive, of the annual QOF submission.

However, it's worth obsessing over as this single submission
earns up to a third of practice income and an even greater
share of profits. It's important that after a year of work the
practice receives the full payment due.

The sight of tinsel in the shops always makes GPs
think of flu jabs, and recently the shelves lined with Easter
eggs will start to remind some health professionals, possibly
the more obsessive, of the annual QOF submission.

However, it's worth obsessing over as this single submission
earns up to a third of practice income and an even greater
share of profits. It's important that after a year of work the
practice receives the full payment due.

Practices have become good at getting high numbers of The sight of tinsel in the shops always makes GPs
think of flu jabs, and recently the shelves lined with Easter
eggs will start to remind some health professionals, possibly
the more obsessive, of the annual QOF submission.

However, it's worth obsessing over as this single submission
earns up to a third of practice income and an even greater
share of profits. It's important that after a year of work the
practice receives the full payment due.

Practices have become good at getting high numbers of
points and many are at maximum or as near maximum as it
is feasible to get. For these practices increasing point score is
not an option.

In 2011, however, prevalence figures are more important
than ever. This is the second year without the square root
formula and the first without the 5% rule.

The detailed workings of the 5% rule are probably best left
in the past but its effects have been to remove the prevalence
adjustment for a lot of practices in England.

In mental health, learning disabilities and dementia there
was virtually no adjustment made and more than a third of
practices were affected in half of the clinical areas.

This change is good news for practices with above average
prevalence their income will rise. However, for practices with
lower prevalence income from the clinical areas could drop
significantly – with no minimum.

It is certainly worth looking at prevalence figures to make
sure that you are being paid all that you are due and your
practice will not lose out due to coding problems. An added
feature is that work done now will continue to pay off in
future years.

The converse is that adding patients to disease registers can have a significant effect on income. This can be more
than £100 per patient in mental health areas. Areas that have
a lot of points and generally low prevalence will have a high
reward for additional patients on the register.

This assumes of course that all the points have been
gained in that area already. In our practice we found a
number of patients who had had good care but were missed
off the disease register.

The exact gain depends on the national average
prevalence but a guide based on last year's figures is shown in
the table.

Time is short but the potential gains can be large. It is,
of course, worth concentrating on where the most reward
can be gained for the least effort. In most cases that means
identifying work that has already been done.

Although adding a patient to the hypothyroid register
does not have a large cash value, a search for patients being
prescribed thyroxine without a hypothyroid code takes only a
few minutes.

Slightly more complex is the obesity register. Patients are
included in the register automatically if they have a body mass
index (BMI) of more than 30 recorded in the previous 15
months.

I found in my practice that a number of patients had
weight recorded without BMI. All but the tallest of patients
with a weight over 90kg will be regarded as obese, and so
searching for these patients fairly quickly increased the
register size.

The two areas where each addition to the register is most
valuable are mental health and dementia care. Many of these
patients are likely to be well known to the clinicians in the practice.
Patients who are prescribed lithium are added
automatically to the mental health register, but patients on
other medications for bipolar disorder, such as valproate
sodium, are not.

It can be worth searching for these and other
antipsychotic drugs, although some may be used for
conditions other than mental health problems. An audit
of patients referred to mental health services or memory
clinics throughout the year may also reveal patients whose
diagnosis has not been correctly coded.

A complex area worthy of consideration is depression.
Depression prevalence is unusual. First there are two
prevalence used. The first relates to the 'two question'
depression screening for people with chronic physical
disease.

The second is applied to the depression assessment for
newly diagnosed patients. This is the use of PHQ-9, HAD
or other assessment tool. While the points to be gained
only apply to new diagnoses of depression in the previous
16 months, the register is based on the number of current
patients who have ever had a diagnosis of depression.

A diagnosis of depression in 2002 or even 1952 will
increase the prevalence adjustment and the value of points
without adding any clinical obligation to the practice.
Good notes summarisation can pay dividends now and
in years to come. This register is not displayed on some
practice systems and you may need to log in to QMAS to see
where you currently stand.

Diabetes must be coded as type one or type two using
codes C10E, C10F or their child codes. Other codes were
used in the past and indeed their descriptions may be
identical to the current codes. EMIS systems include a tool
in their population manager to identify these patients. With
a potential income of £50 a year by correcting the codes, it
only takes one to make a search worthwhile.

Of course, QOF is like the painting of the Forth Bridge.
It never stops, you just move back to the beginning again.
In fact with many of the indicators looking back over 15
months we are starting the next year before finishing the
first.

There are, however, likely to be some changes for the
year 2011-12. Negotiations were ongoing at the time of
going to press but you can get ahead of the field by making
sure that all patients on the mental health register have a
blood test for glucose, cholesterol and HDL.

They will also need blood pressure, BMI and a record of
alcohol consumption. Similarly for patients with a diagnosis
of dementia after 1 April, make sure that they have bloods
including B12 and folate soon after diagnosis. None of
these have been confirmed at the time of writing but could
allow you to get ahead of the game for the coming year with
relatively little effort.

Above all, QOF is complicated and regularly changes.
Keeping abreast of these changes and monitoring
performance throughout the year is the key to maintaining
achievement and income.

[[QOF table]]
 

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