Once more unto the breach, dear friends: QOF 2013/2014

Welcome to the brave new world!  The new financial year brings a new NHS: crusading clinical commissioning groups, the dreaded CQC and the steady hand of NICE driving QOF ever onwards.

The dust has barely settled on our QMAS sign off but attention must turn to the QOF 2013/2014.  There are several changes and some we must act on now or points will be lost for good before we even realised we started.

It’s worth noting that England, Wales, Scotland and Northern Ireland now all have slightly different QOFs, though by and large the new clinical indicators are the same throughout.  

Major clinical changes are seen for depression, diabetes and hypertension and there is a new domain for rheumatoid arthritis.  For all the indicators, thresholds and codes download for free our new Keep It Simple Guide to QOF 2013/2014 at www.nbmedical.com/downloads.   

Depression

All change.  First the good news: PHQ-9s are out and case finding in DM/CVD is dropped.  The bad news is that they are replaced by an 11 part “bio-psychosocial assessment” which must be documented on the day of diagnosis or you lose the huge 21 points available.  Official guidance suggests the 11 parts include:

•  Current symptoms including duration and severity 
•  Personal history of depression
•  Family history of mental illness
•  The quality of interpersonal relationships with, for example, partner, children and/or parents
•   Living conditions
•   Social support
•  Employment and/or financial worries
•  Current or previous alcohol and substance use
•  Suicidal ideation
•  Discussion of treatment options
•  Any past experience of, and response to, treatments

Of course, we do all this naturally in depression cases but now we have to document it all -  there are no specific codes at present but apparently the authorities will be checking our entries at some point!  We have written a useful questionnaire (déjà vu anyone?) covering all these points for patients to complete – feel free to copy and modify it from our blog.   

A practical approach may be to initially code “low mood”, then gather the information and formally code “depression” at follow up.  Most of us would be reluctant to diagnose depression on the first consultation in any case, given the amount of stress or other causes we see, so I don’t really see this as fudging it, more being a good clinician.

A follow up review is required after 10-35 days for a further 10 points.  We need to note symptoms, social support, alternative treatments, follow up on external referrals and enquire again about suicidal ideation.

You might start begging for those PHQ-9s back by the end! 

Diabetes

Three new areas for diabetes:

•  All patients must receive dietary advice from a suitably competent professional – this doesn’t include us or our practice nurses!  Effectively meaning a dietician, this may require referral – realistically overwhelming all our local services… (Note they had to withdraw indicators for cardiac and respiratory rehab referral for that very reason.)
•  Newly diagnosed diabetic patients from 1/4/13 must be referred to a structured education programme within 9 months.  This follows evidence we’ve presented on the course about the long term benefits of lifestyle change both for those with diabetes and pre-diabetes.  However, while these programmes exist in much of country, locally we’re told they won’t be able to cope with the demand… 
•  All male patients with diabetes will need to be asked about erectile dysfunction, recording advice, contributory factors and treatment options.  On the face of it this may seem like an intrusion too far.  But quite apart from addressing the negative psychosocial aspects, ED is often the first marker of CVD so merits further assessment.  What’s really interesting is that lifestyle modification and drug therapy to modify CV risk factors is good not just for the heart, but improves sexual function as well.  A message worth selling. (Arch Intern Med. 2011;171(20):1797-1803)

Hypertension

The main change here is a drive to assess physical activity.  For this we must use the GPPAQ - General Practice Physical Activity Questionnaire.  Very easy to do; takes about a minute.  Patient.co.uk have a quick online version.  The relevant Read codes are: 138X. for inactive, 138Y. for moderately inactive, 138a. for moderately active, and 138b. for active.

Patients who are less than active (so the first 3 categories) need a “brief intervention” – the government recommendation is for 30 minutes activity on 5 days a week or more. 

Rheumatoid Arthritis

It has been known for a long time that people with RA have a greater risk of cardiovascular disease and fracture than the general population.  QOF now recognises this and aims to encourage assessment.  We will need a register, annual face-to-face review, CVD risk assessment in those aged 30-85 and fracture risk assessment in those aged 50-91.  Not too onerous and quite reasonable in the grand scheme of things.

The big squeeze

Most of the other domains stay the same as last year in theory, but take a close look at the payment thresholds and you’ll see many of them have gone up, making it increasingly difficult to reach those upper targets.   Also rather than a 15 month window we will now only have 12 months to get all the checks done.  We are going to need to make every patient count and be ruthless with exception reporting.

So good luck.  It’s going to be a very interesting year for general practice! 

Neal

Addendum:

The disparaties between the countries of the UK have become more pronounced in this year's QOF (and the BMA more effective the further you get from Whitehall). Whilst the clinical indicators are essentially the same, the amount of current implementation between the countries varies and outside England the organisational domain remains in some form.

Worth casting you eye over, I've included the most relevant links I could find. If you have any extra or more up to date info please share!

Scotland:
http://bit.ly/137R8Zp

Wales:
http://bit.ly/15anXZz
(This is a BMA presentation from Jan, so if anyone has more up to date info please let me know)

Northern Ireland:
http://bit.ly/17BZegy

Other useful links:

Blog:      http://nbhottopics.blogspot.co.uk/2013/04/template-for-new-qof-assessment-of.html

KISS Guide to QOF: www.nbmedical.com/downloads

Full QOF: http://www.nhsemployers.org/Aboutus/Publications/Documents/qof-2013-14.pdf

Summary of changes: http://www.nhsemployers.org/SiteCollectionDocuments/Summary%20of%20QOF%20changes%202013-14_ja250313.pdf

GPPAQ: http://www.patient.co.uk/doctor/General-Practice-Physical-Activity-Questionnaire-%28GPPAQ%29.htm