004B Routine QOF work | g Disengaged

004B Routine QOF work | g Disengaged

This folder focuses on patients who appear to be disengaged from care, having missed out on routine monitoring across two QOF years.


🧾 DISENGAGED | Asthmatics who didn't have a review last year

Supports AST007
Asthma patients with no recorded annual review during the previous QOF year.

  1. These patients may be disengaged or at higher risk and are suitable for proactive contact.

🧾 DISENGAGED | COPD010 and didn't have a review last year

Supports COPD010
Patients with a COPD diagnosis who missed their annual review last year.

  1. Likely to be disengaged and clinically at risk — useful for prioritising outreach.

🧾 DISENGAGED | Diabetes no HbA1c this year or last year

Supports DM020/021
No HbA1c test in the last two QOF years. Likely disengaged — prioritise recall.

🧾 DISENGAGED | DM012 Foot risk not assessed last year

Supports DM012
Patients missed their diabetic foot check last year. May be at clinical risk and miss DM012 if not reviewed this year.

  1. Prioritise for invitation, especially if they have already been seen in clinic
  2. Identify patients managed by secondary care - have they been assessed there, but not coded?

🧾 DISENGAGED | HF007 No review this year or last year

Supports HF007
Patients who have missed two consecutive years of HF review.

  1. These are often disengaged and at increased risk — useful for proactive outreach or exception coding.

🧾 DISENGAGED | Mental health patients who didn’t have a care plan last year

Supports MH002
Patients who did not have a coded care plan in the previous QOF year.

  1. Indicates disengagement or missed care – ideal for recall or exception coding review.

🧾 DISENGAGED | No BP last year previous BP above target

Supports CHD015/016, DM036, HYP008/009, STIA014/015
Patients with any of CHD, hypertension, stroke, diabetes (under 80 not frail) with no BP reading this year, or the previous contract year.
The most recent blood pressure reading was above threshold for their current age.
  1. Alongside similarly named report, use this to prioritise patients for urgent invitation
  2. These patients may be hard to reach or no longer engaging with the practice.
  3. Worth considering for targeted outreach, welfare checks, or PCA coding where appropriate.
  4. This group is at significant risk of being missed entirely unless followed up deliberately.

🧾 DISENGAGED | No BP last year previous BP below target

Patients with any of CHD, hypertension, stroke, diabetes (under 80 not frail) with no BP reading this year, or the previous contract year.
The most recent blood pressure reading was below threshold for their current age.
  1. These patients may be hard to reach or no longer engaging with the practice.
  2. Worth considering for targeted outreach, welfare checks, or PCA coding where appropriate.
  3. This group is at significant risk of being missed entirely unless followed up deliberately.

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