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The New General Medical Services Contract (nGMS) for NHS general practitioners changes the way GPs are remunerated. Under the contract GPs are paid performance-related income according to a Quality and Outcomes Framework (QOF)—essentially a list of clinical and other standards associated with points (income) for achieving certain target thresholds. One of the informatics challenges of nGMS is therefore the recording of activity in a consistent and efficient manner.

Clinical system templates

If a patient has a condition that is singled out by nGMS (e.g. asthma, diabetes, etc.) then the easiest way to record data would be to have the system prompt the GP for anything that is missing (as EMIS does, the system I use at work). There are a few of problems with this approach:

• The template serves the dual purpose of maximizing QOF points and of managing the patient clinically. You might think there is no conflict here, and although there is some overlap, there is more to managing patients than gathering points. Consequently, the templates can be bloated with requests for data input not required for QOF and it is difficult to see what is "essential" from a points perspective. When time is limited—as it often is—sometimes you might choose to ask the questions or perform the tasks that really "count";
• The templates may contain a confusing selection of Read Codes (or Clinical Terms if you prefer). Even before you get into the template you have to code the condition correctly. Because the Read Codes are often not intuitive, consistent, logical, etc. it helps consistency if you type in the actual code, rather then a string of English that presents you with a hierarchy of choice;
• The templates and a list of "prefered" codes are not available on home visits. Although you can print out a template to take on a visit, this requires the foresight to do it for each QOF condition that the patient may have, and doesn't allow for patients with a new diagnosis or where the condition has not been correctly Read coded or otherwise identified prior to the visit.

The essentials on one side of A4

Partly in an attempt to address the above issues, and partly to get a handle of QOF for myself, I set myself the challenge of producing a document that contained all I needed to know about QOF (clinically) on one side of A4. I also wanted an "at a glance" way of knowing how often things needed checking, so I could tell the patient when I was expecting to see them next. Luckily for me Lee Cramman with the help of emis-list members had been working on something similar (as a multi-page text list). I've combined my reading with his draft list and discussion in our practice to produce the chart below.

The basic equation for checking QOF status is Green (all patients) plus Orange (QOF condition) minus Red (exceptions):

You can download the checklist as a PDF file (170 KB approx., last update 29.11.05) by clicking here.

Feedback, especially suggestions for improvements or amendments, is most welcome.

Update 09.06.06: New QOF indicators for 2006/2007 are available, which introduce several new conditions to the Framework. I'll not be updating my checklist as I am soon to leave the NHS (so will not be using the codes) and there is now too much information to fit comfortably on a single side of A4. Dr Simon Clay, a GP in Erdington (Birmingham UK), has produced 3 excellent Excel spreadsheets that summarize the clinical indicators (targets, codes, points & ranges by disease) and approved exception codes. With the kind permission of Dr Clay, you can download these below.

Download a summary of QOF diseases (from April 2006) with lecture notes here (Approx. 50 KB .zip file; requires Excel and Word). © Dr Simon Clay 2006.

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