QOF Income including the impact of prevalence

QOF Income including the impact of prevalence

Income Protection

For the year 2024/25 a number of QOF indicators have been "income protected".  See our separate support article for more details about this.

Aspiration payments

Aspiration payments are funded at 80% of the previous year's unadjusted achievement OR as agreed with the board.

Achievement payments

First, a calculation is made of the Practice's % achievement for the QOF area (D).  This is calculated from the following fraction:
A/(B-C) x 100 = D                                                                                                                                                                                                                     
  1. A is the number of patients registered with the contractor in respect of whom the task has been performed or outcome achieved
  2. B is the total number of patients registered with the contractor with the relevant medical condition
  3. C is the total number of patients who have a personalised care adjustment recorded as well as the total number of excluded patients
To calculate the number of points achieved  (H)  the following calculation is used:
(D-E)/(F-E) x G = H                                                                                                                                                                                                                        
  1. D is the % achievement just calculated
  2. E is the minimum percentage score set for the indicator
  3. F is the maximum percentage score set for the indicator
  4. G is the total number of points available for the indicator

Once the points have been calculated, some parts of QOF are adjusted by the Adjusted Practice Disease Factor (APDF), others are not.  APDF is a method of adjusting the value of the QOF point to account for prevalence - which makes sense, because if you have more patients with a condition it follows that you need more funding to provide care for them.

Indicators not subject to APDF

Cervical screening

For the cervical screening indicators, the achievement points total is calculated by:

  1. A is the number of patients registered in the relevant target population
  2. B is the contractors registered population at that date
  3. C is the average number of patients registered with all surgeries
  4. D is the average contractors registered population for England
  5. E is the achievement points
  6. F is the cash paid

Other QOF areas:

The part of the Achievement payment that relates to 
  1. the Palliative Care area of the clinical domain
  2. indicator 004 in the Smoking area of the public health domain
  3. indicator BP002 in the Blood Pressure area of the public health domain
Is calculated by multiplying the total number of achievement points gained by the contractor by the value of the QOF point for that year.

Adjusted Practice Disease Factor

The rest of the indicators are subject to APDF.  The Raw practice disease prevalence is the number of patients on the relevant disease register at 31st March in the financial year to which the payment relates divided by the the Contractors Registered Population (CRP) for that date.
The Adjusted Practice Disease Factor (J) is calculated by the formula: 
H/I = J                                                                                                                                                                                                                                                                  
  1. H is the Raw practice disease prevalence
  2. I is the national raw disease prevalence in England for that indicator
So finally for those indicators subject to APDF the calculation used to calculate the value of achievement for that indicator is:
APDF * value of QOF point for the contract year * points achieved                                                                            

Adding up all the values

Each indicators income is then added together to give the cash total in respect of the domain.  These cash totals are then added together and multiplied by the contractor's CPI.  The CPI is the contractor's most recently established Contractor Registered Population (CRP) divided by the national average for England of the number of registered patients of contractors on the 1st January in the year immediately before the commencement of the financial year to which the Achievement Payment relates.  For the financial year ending 31st March 2024, the national average practice population figure is 9,964.

Is it worth spending tons of time maximising practice prevalence?

There are a number of factors to consider when answering this question, but we would recommend following the general premise of:
Make sure you accurately code all patients, because then they'll be on the correct disease register and you will appropriately care for them and be appropriately funded for them 
Spending many hours ploughing through lists of patients trying to chase technicalities to add patients to your disease registers can be counterproductive.  This is because of a number of different factors:

Your prevalence is rebased each year

If every Practice in the country is doing lots of work to improve their prevalence, the national prevalence will go up and so next year the value of your prevalence will be reduced.  Indeed the only way it can work is if your prevalence is consistently above average year on year, which is a challenge.
If you look at prevalence from 2004 to now:
  1. Asthma has increased from 5.8% to 6%
  2. Cancer has increased from 0.5% to 3.2%
  3. COPD has increased from 1.4% to 1.9%
  4. Diabetes has increased from 3.4% to 5.8%
  5. Heart failure has increased from 0.4% to 0.9% 
  6. Hypertension has increased from 11.4% to 13.9%
  7. Mental health has increased from 0.5% to 0.9%
  8. Stroke has increased from 1.5% to 1.8%
We know that prevalence is increasing year on year, hopefully because Practices are becoming better at clinical coding and appropriately caring for patients, but the overall pot of income for QOF has not gone up (except by negotiated contractual increases). This all means an average Practice will have higher disease registers, be doing more work, but be paid the same.

If you increase your prevalence, you will have more work to do to achieve your indicators 

If you have more patients on a disease register, it follows you will need to do more work to achieve the indicator targets in this area.  In fact the value of QOF points closely follows the amount of work that is needed for that area.
You may also not achieve full marks in that indicator because of the increased workload, which wiil certainly derail any planned increase in income.
Also if you increase your prevalence in a register with no achievement (e.g. CKD) you may well find that targets appear in future QOF years which you will then find it hard to achieve.

A worked example of the impact of chasing prevalence:

In the following table you can see each of the QOF areas subject to ADPF, with the points for that indicator.  The next column shows the average prevalence for England and if we assume that a Practice achieves a 20% on this, that is shown in the next column.  The increased income from the increased prevalence is seen in the next column.  Looks good right?
Well that's only half the story.  As with any business turnover is vanity and net profit is sanity, so yes you'll increase your turnover, but now let's look at the impact of the additional work.  In the next column you can see the additional number of patients you would need to care (or achieve the target for).  To give a better idea of the work you can see for each of the indicators the income that you would get additionally for each patient.   This is widely variable, but you can also see that the bigger areas are also those where there is more work needed.  For those indicators where there is not much to do, the increase from the prevalence is very little.

Area Points Avg Prevalence 20% uplift Increased income Additional pts Income per patient
Asthma 45 6 7.2 1810.44 96 19
AF 29 2 2.4 1166.73 32 36
Cancer 13 3.2 3.84 523.02 51 10
CHD 28 3 3.6 1126.50 48 23
COPD 19 1.9 2.28 764.41 30 25
Dementia 44 0.7 0.84 1770.21 11 158
Depression 10 9.8 11.76 402.32 157 3
Diabetes 67 5.8 6.96 2695.54 93 29
Epilepsy 1 0.6 0.72 40.23 10 4
Heart failure 29 0.9 1.08 1166.73 14 81
Hypertension 25 13.9 16.68 1005.80 222 5
LD 4 0.5 0.6 160.93 8 20
MH 38 0.9 1.08 1528.82 14 106
Osteoporosis 3 0.3 0.36 120.70 5 25
PAD 2 0.6 0.72 80.46 10 8
RA 6 0.6 0.72 241.39 10 25
Stroke 11 1.8 2.16 442.55 29 15

Remember we also haven't costed all the time that has been spent by administrators or clinicians running searches to look at prevalence, chase patients, explain diagnoses and then organise recall for them!

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