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					       The QOF 2006/07
Strategies for gaining full points
          Kathie Applebee
2006/07 – 1,000 QOF points
 Clinical              655
 Holistic care          20

 Organisational        181
 Additional services    36
 Patient experience    108
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
          Identify the patients

• The values of the clinical domain points
  depend on the size of your practice and the
  numbers of patients in each disease area
  (except palliative care)
• Improve your prevalence to improve patient
  care and increase the value of your points
    Potential patients for registers

• On repeat medication, without prescribing
• With disease entries but wrong codes used –
  not picked up by IT system/QMAS
• With high BP, cholesterol etc. records but
  lacking diagnosis and/or treatment
• Lacking investigative procedures eg no BP
            Examples of codes to check
•   Coronary heart disease   14AA. H/O: heart disease NOS
•   Heart failure            1O1..00 Heart failure confirmed
•   Stroke and TIA           14A7. H/O: CVA/stroke
•   Hypertension             14A2. H/O: hypertension
•   Hypothyroidism           1432 H/O: hypothyroid disorder
•   Diabetes                 1434.00 H/O: diabetes mellitus
•   Mental health            146.. H/O: psychiatric disorder
•   COPD                     66YL.11 COPD follow-up
•   Asthma                   14B4.00 H/O: asthma
•   Epilepsy                 1473.00 H/O: epilepsy
•   Cancer                   142..00 H/O: malignant neoplasm
•   Dementia                 1461. H/O: dementia
•   Chronic kidney disease   1Z1..00 Chronic renal impairment
•   Atrial fibrillation      14AN. H/O: atrial fibrillation
•   Learning disabilities    ZV40000 Problems with learning
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
                 Do the work

• Why do some patients miss out?
  –   Don‘t attend
  –   Don‘t help themselves eg attending when asked
  –   Aren‘t pushy: don‘t like to bother the doctor
  –   See stressed / lazy / IT-slow clinicians
  –   Can‘t be identified due to IT problems
        Clinician needs to know…

•   That a patient is in a register
•   What needs to be done
•   Where to record it
•   How to do it

Easily, quickly, part of normal clinical process
        Understanding the work
• Targets which need action eg recalls to
• Combine targets (eg cholesterol and BP
  done by HCA)
• Work which can be done during
  consultation eg medication reviews
• Targets in the correct time frame –
  understand the time-specific targets
         Why doesn‘t it happen?
• Audit clinical encounters to find out who does
• Use any available IT facilities to help with spot
• Take advantage of opportunistic encounters eg flu
• Train non-clinical staff to look out for patients
  with apparent gaps, and offer them appointments
  or get them followed up
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
             Record the data

• Know how to use the computer
• Be able to differentiated between different
  screens, fields and ways of entering data
• Understand Read codes
• Use free text judiciously
• Follow referral and recall systems
          Understand Read codes

• Codes beginning A-Z = diagnostic
• Codes beginning with a number
  –   symptoms
  –   signs
  –   investigations
  –   procedures
  –   administration
            Codes and terms

• Preferred term - Acute myocardial
• Synonym - Heart attack
• Acronym - MI
• Read Code - G30..
      Common coding errors - 1

• Family history as an actual disease
• History of a disease without a date of
  occurrence of disease
• A disease code with qualifying free text to
  indicate absence of a condition
• The date of entry instead of the date of
       Common coding errors - 2
• A diagnosis when symptoms would be more
• A procedure (syringing the ears) without
  associated morbidity (excess ear wax)
• A morbidity entered instead of an immunisation or
  test; e.g. tetanus instead of tetanus immunisation
• Neonatal problems in a mother‘s record, or birth
  details in the baby‘s record (e.g. Caesarean
               Read codes

• Required Read codes available at
  45.php (or follow link from foot of
• Be aware of changes to the Business Rules
  which dictate the QOF Read codes
Summary of changes from Version 8
and Version 8.5 of the QOF Business

Depression: A new denominator rule has
been added to Indicator 1 (patients with
CHD or diabetes) to exclude
patients with a current diagnosis of
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
           Run recall systems

• The job of the recall clerk is to match
  patients in need of reviews or treatment
  – With the correct clinician
  – At suitable places, dates and times
  – Who has the job(s) of getting the patient there
    (on time)? Should the practice remind patients?
              Which recalls

• Identify all recall areas, including those
  done by individuals eg nurse-led clinics
• Calculate the numbers of patients in each
  disease area
• Find out how often each type of patient
  needs to be recalled routinely
       Understanding the problems
• Identify the resources available
  –   GPs
  –   Nurse practitioners and nurses
  –   Health care assistants and phlebotomists
  –   Admin staff
• Plan the year: 52 weeks, less
  – Easter and Christmas period
  – Half terms and main summer holidays
             Identifying patients

• Searches
  – Conditions
  – Medication
  – Test results or lack of any of these
• Recalls
  – Plan how to log recalls
  – Ensure old ones deactivated
  How to handle patients with multiple
• Identify various groupings eg diabetics with
• Flag patients to prevent multiple recalls
• Consider ―multiple problem‖ data entry
  screens and/or clinics
 Single or multiple chronic diseases

• Instead of calling by disease, recall by
  patient eg in the month of their birth
• Recall them into specific clinics, if one
  chronic disease only, or
• Recall them into multiple disease sessions
• Appointments for these range from 20
  minutes upwards
                  Data entry
• Draw up recall data entry guidelines for:
  – Recall staff (administrative entries)
  – Clinicians (clinical entries)
• Agree follow-up protocols
  – How long to wait before second approaches
  – Who should contact certain patients
• Complete other relevant entries eg
  medication reviews

• Ensure all new registrations/diagnoses have
  1st invites to relevant clinics
• Ensure remaining patients have one-year (or
  less) recalls set
• No scripts to be given for more than a year
           Monitoring recalls

• Check monthly recall figures against annual
• Have contingency plans for practical
  problems eg sickness
• Monitor QOF targets monthly, both for
  prevalence and for completion
• Target problem areas from November
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
           Log and chase DNAs

•   How are the invitations recorded?
•   What about verbal invitations?
•   How are DNAs logged?
•   How are DNAs followed up?
             DNA Protocols

• Protocols for identifying and recording
  DNAs for receptionists and clinicians
• Decide when different types of patients are
  removed from this year‘s (or permanent)
• Invite exceptions, and exception report
  QOF patients (where appropriate)
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
           Exception report

―Practices may be called on to justify why
they have excepted patients from the QOF
and this should be identifiable in the clinical
   Overriding principles for exception
              reporting - 1
• It should be based on clinical judgement
  with documented explanation
  – Read code the exception code
  – Free text the explanation/reason…
The percentage of patients with
coronary heart disease whose notes
have a record of total cholesterol in
the previous 15 months
Excepted from CHD quality
indicators: Patient unsuitable 9h01
Comment: needle phobia
   Overriding principles for exception
              reporting - 2
• No blanket exclusions: each case should be
  considered on its own particular set of
  relevant factors
• For example:
  – Do not exclude all patients over a certain age eg
    no cholesterol tests for patients >75
  – Do not exclude patients with a certain condition
    eg no spirometry for patients with dementia
     New patients/new diagnoses

• Patients newly diagnosed within the
  practice or who have recently registered
  with the practice
• Measurements made within three months eg
  take BP
• Delivery of clinical standards within nine
  months eg meet BP target
                Time lines

• Patients registered or diagnosed on or after
  1 July must have their measurements/tests
  done within 3 months but their scores will
  not count towards the current QOF year.
• Patients registered or diagnosed on or after
  1 January will not count towards the current
  QOF targets.
• Patients who have been recorded as refusing
  to attend review who have been invited on
  at least three occasions during the preceding
  twelve months.
• These patients are excluded from all
   Invitations to attend must be patient
• Not a generic invitation on the right hand
  side of the script, eg to attend for flu
• Not a notice in the waiting room inviting
  particular groups of patient to attend, eg for
  asthma reviews
             Informed dissent

• Where a patient does not agree to
  investigation or treatment (informed
  dissent), and this has been recorded in their
  medical records.
  – Patients not responding to invitations or failing
    to arrive at appointments should not be
    classified as informed dissent
        Inappropriate treatment

• Patients for whom it is not appropriate to
  review the chronic disease parameters due
  to particular circumstances eg terminal
  illness, extreme frailty.
• These patients are excluded from all

• Patients who are on maximum-tolerated
  doses of medication whose levels remain
• Where a patient has not tolerated certain
• Patients for whom prescribing a medication is not
  clinically appropriate eg those who have an
  allergy, another contraindication or have
  experienced an adverse reaction.
• Where the patient has a supervening condition
  which makes treatment of their condition
  inappropriate eg cholesterol reduction where the
  patient has liver disease
             Lack of facilities

• Where an investigative or secondary care
  service is unavailable.
  – In the event a practice indicates an investigative
    or other specialist service is not available,
    agreement should be reached with the PCO
    Causes of low exception reporting

•   Lack of understanding of regulations
•   Feeling that it is ―cheating‖ or immoral
•   Sense of not doing enough for the patient
•   Sense of failing as a clinician
•   Concern about labelling certain patients
•   Not knowing how to record them
•   Assuming that admin staff will do it
           Full/high QOF points

•   Identify the patients
•   Do the work
•   Record the data
•   Run recall systems
•   Log and chase DNAs
•   Exception report
•   Constantly monitor progress
      Constantly monitor progress
• Check the prevalence of registers
• Use system reports and QMAS (when available)
  regularly – fortnightly from at least November,
  weekly from January, and daily through March
• Periodically review understanding of QOF
  requirements amongst team members
• Target chosen areas rather than chasing ad hoc
             High value areas – 1
      365 points (55.7%) out of 655 clinical domain points

• Blood pressure checks and management to
  required levels: 148 points (CHD 26,
  stroke/TIA 7, hypertension 77, diabetes 21,
  CKD 17), plus 15 points from the
  Organisational Domain for patients aged
  45+ having BP records every 5 years.
             High value areas – 2
      365 points (55.7%) out of 655 clinical domain points

• Smoking status and cessation advice: 74
  points (68 points in the smoking area and 6
  for teenage asthmatics), plus 11 points from
  the Organisational Domain for patients aged
  15+ having their smoking status checked
  every 27 months
             High value areas – 3
      365 points (55.7%) out of 655 clinical domain points

• Cholesterol measurement and reduction: 40
  points (CHD 24, stroke/TIA 7, diabetes 9)
• HbA1c recorded and treated to 7.5 or less:
  31 points,
• Anti-platelet or anticoagulant therapy: 30
  points (CHD 7, stroke/TIA 4, diabetes 4,
  atrial fibrillation 15)
             High value areas – 4
      365 points (55.7%) out of 655 clinical domain points

• Use of a) ACE inhibitors/A2 antagonists, or
  b) ACE inhibitors/ARBs: 24 points
  (a) CHD 7, diabetes 3; b) HF 10, CKD 4)
• Flu vacs: 18 points (CHD 7, stroke/TIA 2,
  diabetes 3, COPD 6)
New QOF clinical areas – 137 points
•   Mental Health (new indicators) - 9 points
•   Dementia - 20 points
•   Depression - 33 points
•   Chronic Kidney Disease - 27 points
•   Atrial Fibrillation - 30 points
•   Palliative Care - 6 points
•   Obesity - 8 points
•   Learning Disability - 4 points
             Mental health (39)
• Register of patients
  – with diagnoses of schizophrenia, bipolar
    disorder and other psychoses
  – no longer a register of patients with severe
    mental illness consenting to regular reviews
     Clearer definition of register

• Check all existing patients
• Search again for other psychotic patients
• Ask Community Mental Health Team for a
  list of patients that they see
                     Mental health
• Review every 15 months includes
  – a check on the accuracy of prescribed medication
  – a review of physical health including, where
     •   issues relating to alcohol or drug use
     •   smoking and blood pressure
     •   cholesterol checks
     •   risk of diabetes
     •   regular preventive care, eg cervical cytology
         Recording the review

• In the review there should be evidence that
  the patient has been offered routine health
  promotion and prevention advice
  appropriate to their age, gender and health
             Lithium patients

• In the therapeutic range in the past 6 months
  (normally 0.4 - 1.0 mmol/l, unless otherwise
  agreed locally)
• Serum creatinine & TSH in preceding 15
• Check systems for extracting data from
  hospital/CPN letters
     New indicator – care plans 1
• Patients on the mental health register must
  have comprehensive care plans recorded
  which have been agreed with individuals,
  and their families and/or carers – target 25-
  50% (6)
• If a patient is treated under the care
  programme approach (CPA), a documented
  care plan discussed with their community
  key worker is acceptable for the QOF
                   Care plans
1. Patient‘s current health status and social care needs &
2. How socially supported the individual is
3. Co-ordination arrangements with secondary care and/or
mental health services and the services actually being
4. Occupational status
5. Early warning signs
6. The patient‘s preferred course of action (discussed when
well) in the event of a clinical relapse
    New indicator – review DNAs

• Patients who fail to attend for their annual
  reviews must be followed up within 14 days
  of non-attendance ―by the practice team‖
  (or their care workers can be contacted) 40-
  90% (3)
               14-day follow-ups
•    Recall patients/make appointments
•    When patients DNA, have system for
     follow-ups which involves:
    1.   Contacting care worker/carer/patient
    2.   Adding DNA code
    3.   Adding follow-up code after the DNA code
    4.   Recalling patient for next suitable
         appointment (where appropriate)
       Monitoring mental health

• Check practice understanding of reviews
  (medication, physical health and co-
  ordination with secondary care)
• Check monitoring of tests, and systems for
• Extract secondary care data
             New clinical areas
•   Palliative care
•   Dementia
•   Depression
•   Chronic kidney disease
•   Atrial fibrillation
•   Obesity
•   Learning disabilities
               Palliative care (6)
• A ―complete‖ register of patients aged 18+ in need of
  palliative care/support care, wef 1 April 2006 (3)
• This is not limited to cancer patients, but includes any
  patient needing palliative care
• Having patients on the register at any time during the
  year qualifies – no prevalence
• Multidisciplinary ―practice‖ case reviews of all such
  patients at least 3 monthly (3)
          Examples of Read codes
• Palliative care              • ZV57C
• Specialist palliative care   • 8BAP.
• Specialist palliative care   • 8BAT.
  treatment – outpatient
• Specialist palliative care   • 8BAS.
  treatment – daycare
• On gold standards            • 8CM1.
  palliative care framework
• DS 1500 Disability living
  allowance (terminal care)    • 9EB5.
                 Case reviews
• Ensure that:
  – Each patient has a management plan as defined
    by the practice team and that decisions are
    acted upon by the most appropriate member of
    the team
  – The management plan includes preference for
    place of care
  – The support needs of carers are discussed and
    addressed where ever reasonably possible.

• The practice should submit written evidence
  to the PCO describing the system for
  initiating and recording case reviews
• The register will be extracted by QMAS,
  but not the reviews
• But record them anyway!
              Dementia (20)

• Register of patients with dementia (5)
  – Diagnosis can be based on GP opinion
• Review psychogeriatric referrals
• Ask secondary care for a list of their current
  case load
• Ask local care homes and nursing home
• Ask the district nurses and CPNs
              Dementia review
• Patients reviewed in previous 15 months 25-60%
  – An appropriate physical and mental health review for
    the patient
  – If applicable, the carer‘s needs for information
    commensurate with the stage of the illness and his or
    her and the patient‘s health and social care needs
  – If applicable, the impact of caring on the care giver
  – Communication and co-ordination arrangements with
    secondary care (if applicable)
               Depression (33)
• A ‗register‘ of patients with diabetes and/or heart
  disease who have also been screened for depression
  (using two standard questions) in the last 15 months
  40-90% (8)
• A register of patients aged 18+ newly diagnosed with
  depression (during that QOF year) who have had the
  severity of their illness assessed using validated
  assessment tools (excludes post-natal depression) 40-
  90% (25)
      Nice Quick Reference Guide to
―During the last month, have you often been
  bothered by feeling down, depressed or
―During the last month, have you often been
  bothered by having little interest or pleasure in
  doing things?‖
               Assessment tools
• Validated severity measures for use in primary care
  setting (type must be recorded in records):
   – The Patient Health Questionnaire (PHQ-9) Free
   – The Beck Depression Inventory Second Edition (BDIII)
   – The Hospital Anxiety and Depression Scale (HADS)
                  Over the last 2 weeks, how often have you been
PHQ-9                 bothered by any of the following problems?

  1. Little interest or pleasure in doing    7. Trouble concentrating on things,
      things                                     such as reading the newspaper or
  2. Feeling down, depressed, or                 watching television
      hopeless                               8. Moving or speaking so slowly that
  3. Trouble falling or staying asleep, or       other people could have noticed.
      sleeping too much                          Or the opposite—being so fidgety
  4. Feeling tired or having little energy       or restless that you have been
                                                 moving around a lot more than
  5. Poor appetite or overeating                 usual
  6. Feeling bad about yourself - or that    9. Thoughts that you would be better
      you are a failure or have let              off dead, or of hurting yourself in
      yourself or your family down               some way

Not at all / several days / more than half the days / Nearly every day
      Chronic kidney disease (27)
• A register of patients aged 18 and over (levels 3-5)
• BP measured in the last 15 months 40-90% (6)
• BP 140/85 or less (not to be confused with the
  diabetic limit of 145/85) 40-70% (11).
• Patients with hypertesion on angiotensin
  converting enzyme inhibitors (ACE-I) or
  angiotensin receptor blockers (ARB) in the
  previous 6 months (prior to year end) 40-80% (4)

• US National Kidney Foundation classified
  in 5 stages, only stages 3 – 5 are included.
• Affects 5% of population
  – Commoner in black and south east Asian
• Treating blood pressure well prevents
CKD codes

• eGFR does not feature directly in QoF or
  QMAS, but it is a diagnostic tool to help
  build the CKD register
• Stage 3-5 GFR (eGFR) < 60ml/min/1.73m2
         Atrial fibrillation (30)
• Register of AF patients (5)
• Diagnoses from 1 April 2006 confirmed by
  ECGs or specialist opinions (referral alone
  insufficient) – up to 3 months prior or 12
  months after diagnosis 40-90% (10)
• Patients treated with anti-coagulants or anti-
  platelets during the previous 6 months 40-90%
              Checking AF

• System for ensuring ECGs done or patients
  referred and seen (or exception reported)
• Check anticoagulation patients for missing
  AF diagnoses
                Obesity (8)

• Obesity: a register of patients aged 16+ who
  have BMIs of 30 or more, measured in the
  last 15 months (8)
• No way of checking prevalence – measure
  as many patients as possible (height and
  weight) as this area is set to expand
         Learning disabilities (4)

• Create a register of patients aged 18+
  – Combine with DES
  – Ask Community Mental Health Team for their
    Learning disabilities – definition

• A significantly reduced ability to
  understand new or complex information, to
  learn new skills (impaired intelligence),
  – a reduced ability to cope independently
    (impaired social functioning)
  – which started before adulthood (18 years), with
    a lasting effect on development.
Clinical indicators - general
            Blood pressures
• 15 monthly for CHD, stroke, diabetes
• 9 monthly for hypertension
• Maximum BP levels 150/90, except for
  diabetics 145/85 and kidney disease
• 5 yearly for other patients aged 45+
  (organisational domain – 15 points)
                 BP rules

• Be aware of difference between CDM BPs
  and routine 5-year checks
• Do not measure unnecessarily and generate
  inappropriate expectations
• Clinicians must take responsibility for the
  outcomes of BP checks
              Smoking status
• Once only for non-smokers, but must be
  entered after diagnosis of first qualifying
• Every 15 months if:
  – Smokers or ex-smokers, and have
  – CHD, stroke/TIA, hypertension, diabetes, COPD
    and/or asthma (33 points)
  – Are asthmatics aged 14-19 (even if non-smokers)
    (6 points)
               Smoking status
• All other patients, aged 15+ every 27 months
  (once only for non-smokers) (Records – 11 pts)
  – Train receptionists to distribute simple
    questionnaires and enter returned data
  – Remind practice team of need to collect for over-
    75s: include with flu jabs
  – Include questionnaire slips with repeat prescriptions
      Smoking cessation advice

• Every 15 months for smokers with CHD,
  stroke/TIA, hypertension, diabetes, COPD
  and/or asthma (35)
• Literature and appropriate therapy made
  available to all smokers (Information for
  Patients area – 2 points)
            Flu immunisations

• Qualifying conditions
  –   CHD
  –   Stroke or TIA
  –   Diabetics
  –   COPD (but not asthma)
• Season runs September – March
                Flu clinics

• Use these to check QOF data
• Have staff available to check heights &
  weights, smoking status, and give smoking
  cessation advice
• Not good for BPs as raised because of
  jabs/thought of jabs

• Every 15 months for
  – CHD
  – Stroke or TIA
  – Diabetes
• 5 mmol/l or less
Clinical indicators – disease specific
       Coronary heart disease (89)
• CHD register
• Angina diagnoses since 1/4/03 referred for
  exercise testing and/or assessment (3 months prior to,
  or 12 months after, diagnosis)
• Aspirin, alternative anti-platelet or anti-coagulant
  therapy, as appropriate
• On beta-blockers (within the last 6 months)
• On ACE inhibitor or A2 antagonists (within the
  last 6 months) if MI after 1/4/03
          Monitoring CHD - 1
• Angiograms: system for capturing results
• Aspirin (including OTC):
  – Ensure reminders for OTC queries to patients
  – Consider prescribing to ensure that patient
    compliance is monitored
  – OTC entries must be updated (within the last 15
            Monitoring CHD - 2
• Anti-platelet & anti-coagulant therapies: check all
  patients on aspirin, clopidrogel or warfarin have
  appropriate diagnoses
• Beta-blockers: must be taken within the 6 months
  prior to 31/3/07
• ACE inhibitors (or A2 antagonists) if MI after
   – System for identifying new MIs
   – Must be taken within the 6 months prior to
     New indicators: Heart failure (20)
            (previously LVD)
• HF register – patients with heart failure (4) HF1.1
  Rationale Prevalence expected to rise 100%
• Do not use 1O1 (letter O) Heart failure confirmed -
  must be G58%
                  Heart failure
• Diagnoses since 1 April 2006 of suspected heart
  failure (eg 1J60) confirmed by an echocardiogram or
  by specialist assessment (3 months prior – 12 months
  after addition to register) 90% (6)
• Currently treated with an ACE inhibitor or,
  subsequently, ARB (Angiotensin Receptor Blocker)
  80% (10)
             Monitoring HF

• Echocardiograms: system for capturing
• On ACE inhibitors or ARBs : check patient
  compliance within the 6 months prior to
  year end.
          Stroke or TIA (24)

• Presumptive strokes since 1/4/06 confirmed
  by referral for specialist investigation (3
  months prior to, or 12 months after,
• Aspirin or other anti-platelet or anti-
  coagulant therapy, for patients with non-
  haemorrhagic strokes or TIA (all need
  excepting if not appropriate)
      Monitoring strokes or TIAs

• Referrals must be recorded using specified
  Read codes
• Anti-platelet & anti-coagulant therapies: as
  for CHD
• Aspirin (OTC): as for CHD
              Hypertension (83)

• Patients with established hypertension
  –   Based on 3 readings
  –   Exclude episodes of transient raised BP
  –   Exclude raised BP during pregnancy
  –   Prior to diagnosis, use codes for raised blood
       Monitoring hypertension

• BPs must be checked on/after 1 July
• Systems for recalling patients with:
  – No BPs
  – BPs too high
• Protocols for treating/exception reporting
  patients with raised BP
                Diabetes (93)
• Register must show Type 1 or 2 (new Read codes)
• Diabetics aged 17+
• Excludes diabetes during pregnancy
• Those with proteinuria or micro-albuminuria should
  be on ACE inhibitors or A2 antagonists (in 6 months
  prior to year end)
• HbA1c (three levels)
   – Checked
   – 10 or less (or local lab. equivalent)
   – 7.5 or less (was 7.4)
Diabetes Code Changes
        Diabetic checks

• Micro-albuminuria
• eGFR (estimated glomerular filtration
  rate) or serum creatine
• Retinal screening
• Peripheral pulses
• Neuropathy testing
        Monitoring diabetes (1)
• Review clinic protocols to ensure these
  match the QOF requirements and spot
  check entries
• Ensuring checking and recording of test
• Check diagnoses for proteinuria or micro-
  albuminuria (significant results alone are
       Monitoring diabetes (2)
• Protocols for recalling or exception
  reporting raised HbA1cs
• Ensure BMIs correctly recorded
• Retinal screening: should be PCO-approved
• Peripheral pulses and neuropathy testing:
  check whether done by the practice or
                    COPD (33)
• With diagnosis confirmed by spirometry, although
  no longer necessary for long-standing/obvious
  cases (80% target)
• Patients with both asthma and COPD can now be
  on both registers
• Record in the last 15 months of:
   – FeV1
   – Inhaler technique (patients not on inhalers should be
     exception reported)
           Monitoring COPD
• Ensure all possible COPD diagnoses
  confirmed by spirometry (3 months prior to,
  or 12 months after, diagnosis), or patients
  exception reported
• Check systems for checking and recording
  FeV1 and inhaler technique – need to be
  done ―annually‖
                 Asthma (45)
• Asthmatics who have ALSO been prescribed
  asthma-related drugs in the last 12 months
• Practice will also have to report the numbers of
  inactive asthmatics ie no current asthma
• Aged 8+, with measures of variability or
• Asthma review in the preceding 15 months
      Summary of Asthma Review
• Assess symptoms
   "In the last month
      • Have you had difficulty sleeping because of your asthma
        symptoms (including cough)?
      • Have you had your usual asthma symptoms during the day
        (cough, wheeze, chest tightness or breathlessness)?
      • Has your asthma interfered with your usual activities e.g.
        housework, work/school etc?"
• Measure peak flow
• Assess inhaler technique
• Consider personalised asthma plan
          Monitoring asthma

• Check understanding of inclusion in asthma
• If no longer asthmatic, but on asthma
  medication (eg for hay fever), add Read
  code for Asthma resolved
• Check components of asthma review
Smoking anomaly
                   Epilepsy (15)
• Identify patients aged 18+ currently on medication
  (patients without drug medication will not be included)
• Patients aged 18+ with records in the past 15 months
   – Seizure frequency
   – Medication reviews (face-to-face, with patient/carer)
   – Convulsion free for 12 months prior to a review in the last
     15 months
          Monitoring epilepsy

• Not all patients on epilepsy medication are
  epileptic – check for diagnoses
• Seizure frequency/convulsion free: system
  for checking hospital reviews
• Medication reviews: plan these to ensure
  time to find out about seizure frequency
• Use code for epilepsy resolved
          Hypothyroidism (7)

• Patients with hypothyroidism and taking
• TFTs every 15 months
                Cancer (11)

• Exclude non-melanotic skin cancers
• For patients diagnosed within the past 18
  months (of the QOF year end), practice
  review within 6 months of notification
  – Support needs (if any)
  – Review of co-ordination with secondary care
    Monitoring cancer diagnoses

• System for:
  – Capturing diagnoses
  – Doing practice reviews
  – Entering correct code
            Holistic care (20)

• Based on clinical domain
• Calculated by achievement in 3rd worst area

• Go to
The non-clinical domains
      Organisational domain (181)

•   Records & information (87)
•   Information for patients (5.5)
•   Education & training (31)
•   Practice management (17.5)
•   Medicines management (40)
                   BP (15)

R11/17: The blood pressure of patients aged
 45 and over is recorded in the preceding 5
 years for at least:
  – 65% of patients (10)
  – 80% of patients (5)
             Summaries (52)
R15/18/20: The practice has up-to-date
 clinical summaries in
  – at least 60% of records (25)
  – at least 80% of records (8)
  – at least 70% of records (12)
• R19: 80% of newly registered patients have
  had their notes summarised within 8 weeks
  of receipt (7)
              Ethnicity (1)

R21: Recording ethnic origin in 100% of new
 registrations from 1 April 2006
     Refusals can be recorded
             Smoking (11)

R22: The smoking status of patients aged 15+
 is recorded every 27 months (40-90%),
 except that patients who have never smoked
 need have it recorded only once
         Significant event reviews
E7: 12 in the last 3 years (4)
E10: 3 in the last year (3)
• Any death occurring in the practice premises
• New cancer diagnoses
• Deaths where terminal care has taken place at home
• Any suicides
• Admissions under the Mental Health Act
• Child protection cases
• Medication errors
• A significant event occurring when a patient may have
  been subjected to harm, had the circumstance/outcome
  been different (near miss)
            Medication reviews

M11/12: Medication reviews every 15 months
 (minimum 80% standard)
  – Patients on 4 or more repeats (7)
  – Patients on any repeats (8)
Patient experience and
  additional services
               Surveys 1 & 2
• Survey done annually (25)
• Reflection and action plan (20)
  1. Summarises the findings of the survey.
  2. Summarises the findings of the previous year‘s
  3. Reports on the activities undertaken in the past
    year to address patient experience issues.
                     Surveys 3
• Reflection and action plan (30)
  1. Sets priorities for the next 2 years.
  2. Describes how the practice will report the findings to
  3. Describes the plans for achieving the priorities,
     including indicating the lead person in the practice.
  4. Considers the case for collecting additional information
     on patient experience, for example through surveys of
     patients with specific illnesses, or consultation with a
     patient group
Smears : Screening management (7)

CS7: The practice has a protocol that is in line
 with national guidance and practice for the
 management of cervical screening, which
 includes staff training, management of
 patient call/ recall, exception reporting and
 the regular monitoring of inadequate smear
New Scottish Directed Enhanced
        Services 2006
    New Directed Enhanced Services

•   Cardio-vascular Disease (CVD) Dataset
•   Cancer Referral
•   Adults with Learning Disabilities
•   Carers
•   Access
Cardio-vascular Disease (CVD) Dataset

• Compile a CVD risk dataset
  – on all patients between 45 and 64 years of age
  – for whom there are no BP or smoking status
    records since 1 April 2001
  – based on a search run on 1 April 2006
• Apply appropriate clinical interventions
Dataset of selected CVD risk factors
• Age and gender
• Height and weight > BMI
• Past medical history
   – CHD, stroke, diabetes, hypertension
• Family history
   – Heart disease, diabetes
• Tobacco use
   – Current smoker, ex-smoker, never smoked
• Blood pressure
                      Cancer referrals
•       Conduct a review of all new cancer cases
        (excluding non-melanotic skin cancers)
        diagnosed in the year preceding 1 April 2006
    –        Look at the whole patient pathway
    –        Record whether new cases were referred
         •     Urgently, by local protocol (if available) or routinely
    –        Review and discuss the appropriateness of the mode
             of referral for each case
    –        Not compulsory to review cases of deceased patients
 Adults (18+) with Learning Disabilities

• Identify
   – Cause of learning disabilities
   – Severity of disability (mild, moderate, severe,
   – Living & support arrangements
   – Cervical screening status (removed from requirements)
   – Any other major medical problems including
      • epilepsy
      • visual & auditory impairment
      • behavioural problems
• Liaise with relevant outside agencies, by
   – Identifying one person from within the practice team to
     act as an appropriate liaison officer
   – Ensuring appropriate contact with relevant outside
• Identify and address, if possible, any barriers to
  access for people with learning disabilities to
  treatment and appropriate screening (this could be
  done through an annual meeting with outside
• Confirm to NHS Boards by the end of
  December 2006 that:
  – The learning disabilities registers have been set
    up and
  – Liaison and identification measures have been
• A carer is someone, who, without payment, provides help
  and support to a partner, child, relative, friend or
  neighbour, who could not manage without their help. This
  could be due to age, physical or mental illness, addiction or
• A young carer is a child or young person under the age of
  18 carrying out significant caring tasks and assuming a
  level of responsibility for another person, which would
  normally be taken by an adult.‖
• (Princess Royal Trust
            Aims of the DES

• To ensure that the health and social needs
  of carers are identified and (met) that steps
  are taken to maximise the quality of life and
  care for both the carer and the cared for
  person, fully recognising carers as key
  partners and providers of care.
• Produce and maintain a register of people who are
  carers, and flag their medical records
• Liaise with relevant outside local carer agencies (if
  they exist) and social work services by
   – Identifying one person from within the practice team to
     act as an appropriate liaison officer
   – Agreeing a referral process for referring carers
   – Co-operate with any relevant agencies in any initiative
     (such as mailshots, all to be funded by these agencies)
     designed to alert carers to the support that they offer.
• Confirm to NHS Boards by the end of
  December 2006 that:
  – The registers have been set up and
  – Liaison and other requirements have taken
                Access defined - 1
•    Direct contact (face-to-face, by phone or another means
     such as email) where:
    – professional, clinical advice is sought and given
        within 2 working days in accordance with the clinical
        needs of the patient; and
    – a professional, clinical opinion and/or diagnosis is
        required in order to determine a further course of
        action e.g. to treat; to refer or to provide professional
              Access defined - 2
•   Professional means a doctor, nurse or health visitor or
    other health care professional in the practice with which
    the patient is registered, who is competent to deal with
    the patient‘s clinical needs.
•   48 hours means 2 working days, where a patient
    requests a consultation in that time, during the normal
    working hours of the practice, where consultations are
    available as published by the practice.
•   Patients mean those (including temporary residents) who
    are registered with the practice.
  48-hr requirements – one or more of…
• Open access (patients are seen on the same day without an
• ‗Advanced Access‘ (or equivalent) approach with same day
• Practice Accreditation, Training Practice Accreditation, or QPA have
  been awarded and the access criteria have been achieved
• Telephone (or email) access to a member of the primary care team for
  professional advice or a consultation within 48 hours e.g. a booked
  appointment in a doctor or nurse led ‗telephone surgery‘.
• Formally established arrangements for triage by a doctor or a nurse by
  phone or face to face.
• Arrangements for patients to be seen by a doctor, nurse or other
  healthcare professional within 48 hours (or sooner where there is a
  clinical need).
•   Where the patient:
    – does not wish to have contact or be seen within 48 hours
    – specifies a particular professional or individual, where an
      appropriate, alternative professional is available within 48 hours.
    – is offered access within 48 hours but declines
• Requests for emergency and urgent treatment which
  should be dealt with sooner
• Pre-planned courses of elective treatment or care
• Outside the normal working hours of practice.
• Planned closures – e.g. public holidays or staff training.
  006(M)08.pdf – see Annex A for revised
  contract 18 April 2006
  006(M)07.pdf - revisions to new enhanced
  services 18 April 2006

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