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Focus on QOF payments

February 2007

Introduction
This guidance note gives a full breakdown of the methods used to calculate and reward money earned through the Quality and Outcomes Framework (QOF). The information within it is drawn from the Statement of Financial Entitlements which can be accessed on the Department of Health website at www.dh.gov.uk/

You may find it useful to read this guidance along side Focus on Quality and Outcomes Framework Management and Analysis System.

QOF payments in England, Scotland, Wales and Northern Ireland are the same throughout this guidance except on a few points. The guidance note quotes the value per QOF point as 124.60p (for 2006-07). This applies to England, Scotland and Wales. In Northern Ireland the value per QOF point is £122.

When the contractor’s population index is mentioned this also differs in Scotland and Northern Ireland. Please see Appendix 1 for the details.

Aspiration payments
Aspiration Payments are a part payment in advance for expected achievement under the QOF. It can be calculated using one of two methods–

(a) a calculation based on 60% of the contractor’s previous year’s Achievement Payment; or
(b) a calculation based on the total number of points that a contractor has agreed with a PCT that it is aspiring towards that financial year.

Calculating monthly aspiration payments by the 60% method
Based on a practice’s QOF return the Unadjusted Achievement Payment for the previous year is established. That is the QOF cash totals for the previous year multiplied by the contractor population index (CPI) (1). (Generally, this calculation is not possible in the first month of the financial year, and so a Provisional Achievement Payment is established by the PCT.)

The Provisional Achievement Payment is then multiplied by the QOF Uprating Index which for the financial year 2006 to 2007 was 1.0 as the value per QOF point stayed the same as the previous year at £124.60p.

The total of these calculations is multiplied by 60%. This figure is then multiplied by the maximum number of points available under the QOF for the new financial year divided by the maximum number of points available under the QOF in the previous financial year. (For example, in the financial year 2006/07 this was 1000 and 1050 respectively, taking into account the revised QOF total in the 2006 QOF.) The resulting figure is the annual amount of the contractor’s Aspiration Payment, which will be paid in 12 monthly instalments. These instalments will be adjusted as necessary when the correct amount of the contractors Achievement Payments in respect of the previous financial year has been established.

Calculation of Monthly Aspiration Payments: the Aspiration Points Total method
An Aspiration Points Total is agreed between the practice and the PCT. It will be the total number of points that the practice is aspiring towards under the QOF during that financial year. In turn, this agreed Aspiration Points Total will be divided by three. The resulting figure is then multiplied by £124.60, and then by the contractor’s CPI, to produce the annual amount of the contractor’s Aspiration Payment. Again, these will be paid in twelve month instalments over the year.

Achievement payments
There are various methods used to calculate achievement payments. In particular the clinical and additional services payments vary from those within the rest of the QOF.

The clinical domain and additional services payments
Calculation of points in the clinical domain
The clinical domain contains nineteen clinical areas, each containing a variety of indicators. The indicators contain standards against which the performance of a practice will be assessed. Some of the indicators require particular tasks to be accomplished (i.e. the production of disease registers), and the standards contained in those indicators do not have percentage Achievement Thresholds. The points available in relation to these indicators are achieved if the task is completed.

Other indicators have designated Achievement Thresholds, whereby a practice will be assessed by a percentage achievement. The minimum percentage represents the start of the scale (i.e. with a value of zero points); and the maximum percentage is the lowest percentage of eligible patients in respect of whom the task must have been performed or outcome recorded in order for the practice to qualify for all the points available in respect of that indicator.

Where a practice has achieved a percentage score in relation to a particular indicator that is the minimum set percentage or below, it achieves no points in relation to that indicator. If a contractor has achieved a percentage score in relation to a particular indicator that is between the minimum and the maximum set for that indicator, it achieves a proportion of the points available in relation to that indicator. The proportion is calculated as follows.

A calculation is made of the percentage the contractor scores (D). This is calculated from the following fraction: divide–

(a) the number of patients registered with the contractor in respect of whom the task has been performed or outcome achieved (A); by
(b) the number produced by subtracting from the total number of patients registered with the contractor with the relevant medical condition (B) the number of patients to be excluded from the calculation on the basis of the provisions in the QOF on exception reporting (C).

This fraction is then multiplied by 100 for the percentage score.
The calculation can be expressed as:
A ____× 100 = D.
(B – C)

Once the percentage the contractor actually scores has been calculated (D), subtract from this the minimum percentage score set for that indicator (E), then divide the result by the difference between the maximum (F) and minimum (E) percentage scores set for that indicator, and multiply the result of that calculation by the total number of points available in relation to that indicator (G). This can be expressed as:
(D – E) × G.
(F – E)

The result is the number of points to which the practice is entitled to in relation to that indicator.

Calculation of points in the additional services domain
The additional services domain includes indicators related to: cervical screening services; child health surveillance; maternity services; and contraceptive services. The child health surveillance and maternity medical services indicators require particular services to be offered and the points available will be paid if the service is offered to the relevant target population.

The contraceptive services indicators and all but one of the cervical screening services indicators require particular tasks to be performed in relation to a target population, and the points available in relation to these indicators will be paid if the task is accomplished.

One of the cervical screening services indicators has a designated achievement threshold, and the method for calculating points in relation to this indicator is the same as the method for calculating points in relation to this type of indicator in the clinical domain.

Calculation of achievement payments in the clinical and additional services domain
The Achievement Payments for the clinical domain and the additional services domain are determined in the following way.

For clinical domain (other than the area relating to palliative care), a calculation is made of the Adjusted Practice Disease Factor (2) for each disease area, and this is then multiplied by the amount per QOF point (for 2006-07, £124.60) and by the contractor’s Achievement Points total in respect of that disease area.

Achievement Payments for palliative care will be calculated by multiplying the total number of Achievement Points by the value per QOF point (£124.60.)

For the additional services domain, a target population factor is calculated. This is done by dividing the practice’s relevant target population by the contractors registered list size. This is then divided again by the figure produced by taking the average number of patients registered with all practices in the relevant target population divided by the average of all practices registered list sizes. This Target Population Factor is multiplied by the amount per QOF point (£124.60p) and by the Achievement Points obtained in respect of the additional service.

The cash totals for all the diseases in the clinical domain, including palliative care, and all in the additional services domain (as described above) are then multiplied by the contractor’s CPI (as it was at the start of the final quarter of the financial year). From this the PCT subtracts the value of the relevant Monthly Aspiration Payments made over the year to come up with the practices final Achievement Payment.

Calculation of points and payments in the organisational domain
This domain consists of five sub-domains: records and information about patients; information for patients; education and training; practice management; and medicines management. The standards set within them relate either to a task to be performed or an outcome to be achieved. The points are paid in full if the task within the indicator is accomplished or the outcome achieved (ie: the points total for the indicator is multiplied by the amount per QOF point, £124.60p for 2006-07).

Calculation of points and payments in the patient experience domain
This domain contains essentially two indicators, both of which relate to patient experience: the first is about the length of patient consultations; the second, split into three levels, is about patient surveys.

The points available in relation to the first indicator, patient consultation, are achieved when the relevant outcomes recorded in that indicator are met.

A practice receives the points available in relation to the lowest performance level in the patient surveys indicator if -
(a) the practice has undertaken an approved patient survey; and
(b) in the course of that survey, at least 25 questionnaires per 1000 patients registered with the practice have been returned by patients.

For each additional performance level reached in the patient’s survey section, the additional points are available to a practice reaching that level of performance. The highest level of performance will result in a payment for all three levels. The points achieved are multiplied by the amount per QOF point.

Calculation of points in relation to the Holistic Care Payment
Practices will be entitled to a proportion of 20 points as the basis of a Holistic Care Payment. This is a payment designed to recognise breadth of achievement across the clinical domain. In order to calculate the points in respect of this Payment, a practice’s points totals in each of the clinical areas in the clinical domain are ranked on the basis of the proportion it scores of the points available in that clinical area, the points relating to the highest proportion being ranked first. The proportion that relates to the points total that is third-to-last is the proportion of 20 points to which it is entitled as the basis of its Holistic Care Payment.

1. Please see Appendix 1 for details of CPI – the Contractor Population Index
2. Please see Appendix 2 for details of Adjusted Practice Disease Factor (ADPF) Calculations

Appendix 1
CPI – Contractor Population Index
The Contractor Population Index (CPI) reflects the national average practice list size. It is used primarily to allocate QOF payments to practices relative to their list size.

In England and Wales it is currently calculated by taking a contractor’s registered population and dividing it by 5891.

In Scotland it is currently calculated by taking a contractor’s registered population and dividing it by 5095.

In Northern Ireland it is currently calculated by taking a contractor’s registered population and dividing it by 4937.

Appendix 2
Adjusted practice disease factor calculations
The calculation involves three steps:

• first, the calculation of a practice’s Raw Practice Disease Prevalences. There will be a Raw Practice Disease Prevalence in respect of each disease area (other than the area relating to palliative care) for which the contractor is seeking to obtain Achievement Points;
• secondly, making an adjustment to give an Adjusted Practice Disease Factor (APDF);
• thirdly, applying the factor to the pounds per point figure for each disease area (other than the area relating to palliative care).

1. The Raw Practice Disease Prevalence is calculated by dividing the number of patients on the relevant disease register by the contractor’s registered population. The timing of this calculation is usually done at the start of the final quarter of the financial year.

2. The Adjusted Practice Disease Factor is calculated by:
(a) calculating the national range of Raw Practice Disease Prevalences in England (PCTs are to use the national range established annually through the Quality and Outcomes Framework Management and Analysis System (QMAS)) and applying a 5% cut-off at the bottom of the range. Contractors below this will be treated as having the same prevalence as the cut-off point;

(b) once the cut-off has been applied, making a square root transformation to all the contractor prevalence figures. This means that the prevalence distribution will be compressed to a narrower range. It will prevent financial destabilisation of those with the lowest prevalence;

(c) after the transformation, rebasing the contractor figures around the new national English mean (available at the end of each month) to give the Adjusted Practice Disease Factor (APDF). For example, an ADPF of 1.2 indicates a 20% greater prevalence than the mean, in the adjusted distribution. The rebasing ensures that the average contractor (i.e. one with an ADPF of 1.0) receives £124.60 per point,
after adjustment;

(d) thereby, adjusting via the factor the contractor’s average pounds per point for each disease, rather than the contractor’s points score. For example, a contractor with an APDF of 1.2 for CHD will receive £149.52 per point scored on the CHD indicators.

3. As a result of this calculation, each contractor will have a different ‘pounds per point’ figure for each disease area (other than the area relating to palliative care), and it will then be possible to use these figures to calculate a cash total in relation to the points scored in each disease area (other than the area relating to palliative care).