KISS: QOF 2024-25

NHSE - Contract arrangements Feb 2024  QoF 2024/25 March 2024

General:

• Income-protected indicators have ↑: further 13 additional indicators now income protected = 32 in total totalling 212 points (>⅓ of total QoF points); registers need to be maintained in these domains. NB income protected points = achievement points guaranteed at the same level as practice achieved in 2023/24, but note this may not equate to the same income. Majority of income-protected points from registers (81 points) and QI indicators (74 points).
• QoF aspiration payments ↑ from 70% to 80% to aid cash flow. 
• ‘QI’ domain is income protected and remains the same as per 2023/24 (workforce wellbeing and optimising demand and capacity), but for 2024/25 no formal submission of plans or evidence for professional network meetings are needed.
• The information below focuses on the clinical domains and does not discuss the QoF public health domains which include vaccinations and cervical screening.

Notes on clinical domains:

• Blood pressure: Targets refer to clinic readings or equivalent home BP monitoring (HBPM).
  • For targets of 140/90 the HBPM equivalent is 135/85, and for targets of 150/90 HBPM equivalent is 145/85. 
• Lipids: UPDATED INDICATOR for lipid targets for secondary prevention (those with CHD, stroke/TIA and PAD).
  • Target has been relaxed from LDL ≤1.8 mmol/L to LDL ≤2.0 mmol/L (or if LDL not recorded non-HDL of ≤2.6 mmol/L).
  • This now puts QoF in line with the updated NICE guidance NG238 from Dec 2023 which moved to absolute LDL targets for secondary prevention, with a cost-effectiveness analysis concluding the lower ≤1.8 mmol/mol target was not cost-effective, hence the more relaxed target of LDL ≤2.0 mmol/L. 
• Heart failure: It's important to note that the drug management indicators (to use ACEI/ARB and b-blocker) refer to patients with heart failure and left ventricular systolic dysfunction (LVSD) or reduced ejection fraction (HFrEF) <40%.
  • It's an important part of our work to make sure we code correctly people with heart failure based on their LV function, as the management varies depending on LV function.
  • Appropriate codes available include (for those who should be on ACEI/ARB and b-blocker in HF003 and HF006) ‘left ventricular systolic dysfunction’ and ‘heart failure with reduced ejection fraction’ (HFrEF).
  • For patients with preserved ejection fraction there is a code for ‘heart failure with preserved ejection fraction’ (HFpEF).
  • This would be an excellent quality improvement idea - review heart failure cohort and check correct coding.
• Diabetes - Microalbuminuria is defined as ACR ≥3mg/mmol.
• Asthma - Asthma control (part of AST007) should be assessed with a validated questionnaire - either an asthma control questionnaire or (probably more simply) with the asthma control test.
• Mental Health/SMI checks: This set of indicators sums up one of the major criticisms of QoF - lots of tick boxes for documenting data but minimal action to do something about it; this concern has been addressed in the updated 2023 Lester Tool which encourages us to ‘don’t just screen, intervene'; the document gives a flow chart for actions we can take if results are outside screening parameters. See also Rachel's recent blog which discusses this in more detail.
• Learning disabilities (LD) - worth clarifying that people with LD are a heterogenous cohort, but have 3 core criteria - 1) lower intellectual ability (IQ <70 is a useful guide but should not be used on it's to determine someone with LD); 2) significant impairment of social/adaptive functioning; 3) onset in childhood. 
  • This is distinct from people with learning difficulties e.g. specific learning difficulties such as dyslexia.
• Osteoporosis - fragility fractures are fractures that result from low-level trauma e.g. force equivalent to fall from standing height or less; generally they encompass spinal, hip, and wrist fractures, but can be humeral, pelvic or rib; fractures of hands and feet are generally not considered fragility fractures.
• Personalised care adjustments (PCAs) - it's important to remember that there will be not infrequent times when a QoF target is not appropriate (and may actually cause harm) for our patient. 
  • Since 2019 we have been able to use PCAs to adjust care and remove a patient from the indicator, based on clinical judgement and patient preference. The reasons for using a PCA must be clearly documented. Indications: 1) indicator unsuitable for patient; 2) patient choice (following shared decision-making conversation); 3) did not respond to offers of care; 4) service not available (only refers to AST011, COPD014 and DM014).