Understanding QOF exclusions and Personalised Care Adjustments

Understanding QOF exclusions and Personalised Care Adjustments


If you want to read much more detail about the topic, read the relevant year's Technical Annexe.  At the time of writing the previous year was 2021/22 and can be found here
If you're reading this there is a good chance that you're interested in prevalence.  See our article QOF Income including the impact of prevalence to see why chasing prevalence to drive up practice income may be counterproductive.
Is QOF prevalence data affected by exclusions and Personalised Care Adjustments?
This is a common question.  The simple answer is “No”

Background

It helps to understand a bit more how registers, performance, exclusions, and PCAs work:

Disease registers

A disease register is a list of all of the patients with an active diagnosis of a particular condition. The asthma register has a secondary requirement of at least 1 inhaler issue in the past 12 months, while the cancer register is a list of all patients who have had a cancer diagnosis since April 2003, even if they have been declared in remission. For many registers a patient will remain on them for life, but some conditions allow for the diagnosis being resolved (eg: asthma, AF, diabetes, hypertension) which will remove a patient from the register.
Prevalence is defined as the number of registered patients on a particular disease register expressed as a percentage of the total registered population.

Indicator denominators

Indicator denominators are the numbers of patients from the appropriate disease register who are counted for QOF achievement against a specific QOF indicator. Within Primary Care IT resources these are always encased within square brackets [name of resource] for ease of identification.
There can be differences between an indicator denominator and the number on a register because of the indicator definition which may exclude certain groups of patients. The definition logic is always written in a specific order to ensure that a patient who has been excluded from the denominator can be included again if they have subsequently met the requirements for the numerator.
Patients who are on the disease register, but not included in the indicator denominator for definitional reasons, are referred to as exclusions.

Indicator numerators

The Indicator numerator is the number of patients from the denominator who meet the requirements of the indicator. For calculating achievement this is expressed as a percentage of the denominator.

Exclusions

For the purposes of this article, we refer to the term exclusion in the sense of how many staff in Practices have understood them, although technically they are now all called Personalised Care Adjustments. The NHS Digital definition of exclusion is somebody who by definition cannot be in the indicator (eg: patients without microalbuminuria in the DM006 indicator). It can be easier to understand some of the different types by separating the various reasons into exclusions/exceptions and Personalised Care Adjustments.

Some examples of exclusions are:

  1. Those patients who are unsuitable for treatment
  2. Those patients who have made an informed decision to receive no care for the condition
  3. Those newly diagnosed with a condition
  4. Those patients who are newly registered with the practice

Personalised Care Adjustments (PCAs)

Differences between an indicator denominator and the number on a register not due to indicator definition, but rather due to individual circumstances, are referred to as Personalised Care Adjustments. PCAs relate to patients who are on the disease register, and who would ordinarily be included in the indicator denominator. However, they are omitted from the indicator denominator because they meet at least one of the specified PCA criteria (see below for more details about PCA criteria).
Staff may continue to refer to exclusions, exceptions, and PCAs interchangeably. 

Why is prevalence not affected by exceptions?

The relationship between registers, denominators, exclusions and PCAs can be expressed using the following calculation:

Register = Denominator + Exclusions + PCAs


Prevalence is calculated at the register level, so includes exclusions and PCAs.

Prevalence = Register / Practice Population

More detail about Personalised Care Adjustments (PCAs)

The following is taken from the Statement of Financial Entitlements:

As of 1 April 2019, exception reporting is being replaced with a Personalised Care Adjustment (PCA). This will allow practices to differentiate between the following reasons for adjusting care and removing a patient from the indicator denominator:
  1. unsuitability for the patient, e.g. because of medicine intolerance or allergy, or contra-indicated polypharmacy
  2. patient choice, following a shared decision-making conversation
  3. the patient did not respond to offers of care – recording of this will change to capture actual invitations sent to patients
  4. the specific service is not available (in relation to a limited number of indicators only)
  5. newly diagnosed or newly registered patients, as per existing rules.
As with exception reporting applying a PCA to the patient record will remove that patient from an indicator denominator if the QOF defined intervention has not been delivered. It will not result in patients being removed from the disease register or other target population.
The associated changes to data recording and extraction should result in a redistribution of coding work away from year-end and provide better information about why patients are not receiving interventions.
Principles when considering whether a PCA applies to an individual patient practices are reminded that:
  1. the duty of care remains for all patients,
  2. the decision to apply a PCA should be based on clinical judgement, informed by patient preferences, and underpinned by shared decision-making principles, with clear and auditable reasons coded or entered in free text on the patient record,
  3. there should be no blanket PCAs: the relevant issues with each patient should be considered by the clinician at each level of the clinical indicator set and this decision reviewed on a regular basis.
In each case where a PCA is applied then in addition to what needs to be reported for payment purposes (in accordance with the Business Rules), the contractor should also ensure that the reason for the adjustment is fully recorded in a way that can facilitate both safe and effective patient care and audit of the patient record.

Personalisation of care can occur for the following reasons which are listed in the order in which they will be extracted in the business rules:
  1. The investigative service or secondary care service is unavailable (where relevant to the indicator).
  2. Intervention described in the indicator is clinically unsuitable.
  3. The patient has chosen not to receive the intervention described in the indicator.
  4. The patient has not responded to invitations for the intervention described in the indicator (a minimum of two invitations for the intervention in the preceding 12 months, except for the cervical screening indicators. where women should receive a total of three invitations for screening).
  5. The patient has registered with the practice or has been newly diagnosed with the condition of interest in the preceding 3 months and has not received the defined clinical measurements e.g. blood pressure measurement.
  6. The patient has registered with the practice or has been newly diagnosed with the condition of interest in the preceding 9 months and has not achieved the defined clinical standards e.g. blood pressure control within target levels.
It is recognised that patients may meet more than one of these criteria and in these circumstances all reasons for PCA should be recorded in the patient’s record. However, as a patient can only be acknowledged as having a PCA once within the Business Rules for a given indicator, they will be allocated to the first criterion they meet in the hierarchy listed above. For example, where a patient is recorded as having registered with the practice in the preceding 3 months and has also chosen not to receive the intervention described in the indicator, they would be identified in the Business Rules as having chosen not to receive the care.

The hierarchy listed above seeks to prioritise clinical judgement and patient choice over other criteria. Applying this hierarchy consistently in the Business Rules in conjunction with the recording changes support better attribution of the reason for care being personalised, allowing for more meaningful conversations between clinicians, commissioners, and regulators.

CQC

What data might CQC look at, I heard they may look at our exception reporting?
Data has moved on a little since the early contract days of exception reporting.

NHS Reporting

Data is now presented by NHS digital in a number of ways:
  1. Underlying achievement (net of PCAs)
  2. Percentage of patients receiving the intervention
  3. Points achieved as a percentage of QOF points available

Underlying achievement

This is the performance taking into account PCAs.

Percentage of patients receiving the intervention

This is calculated as follows:

Percentage of patients receiving the intervention = (Indicator numerator /  (Indicator denominator + indicator PCAs)) * 100 and hence gives a more accurate picture of how the practice is performing as it includes PCAs

Points achieved as a percentage of QOF points available

This takes into account where practices may not be able to achieve an indicator (e.g. where they don’t have any patients on a particular register) and so gives an indication of how they’re performing as a percentage compared to the maximum that would be possible.

CQRS

What about CQRS data on exception reporting and PCAs?

CQRS wasn't designed to give specific management information about PCAs, but it does include some data on them.  CQRS does not allow a presentation of exceptions broken down by each of the six Statement of Financial Entitlements (SFE) PCA criteria described earlier in the article.


NHS digital explains that there are two reasons for this:

  1. CQRS uses an internal set of PCA ID codes that do not map directly into the 6 PCA reporting criteria in the SFE; rather, these PCA ID codes relate to PCA reporting coding ‘clusters’ within QOF business rules, often specific to individual QOF indicators. Fewer than six of the criteria in the SFE may apply to an indicator.
  2. CQRS reporting functionality does not make a distinction between PCA reporting and definitional exclusions – both types of omission from indicator denominators are included on reports available to CQRS users.    


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