June 17, 2024

Dr David Coleman explores how nurses working in general practice can drive the response to this years’ targets

Reports of the death of the Quality and Outcomes Framework (QOF) in England have been greatly exaggerated — or at the very least they’ve proven to be premature. We’re told next year will see a ‘consultation on the future form and suitability of QOF’,1 but for now the beast is very much alive and as relevant as ever. General practice must make the best of the situation and adapt chronic disease management to hit those all-important targets while also achieving excellence for patients.

Many of you will have encountered post-pandemic challenges with chronic disease management: poor patient engagement; worsening control of HbA1c, blood pressure and asthma symptoms; and lower uptake of cancer screening. This article will suggest potential solutions and, while many practices will have attempted some of these already, I hope you find some helpful tips to make your QOF lives easier in 2023/24.

1: Take another look at your recall systems
Following the disruption of the pandemic period, many patients have fallen out of the habit of attending chronic disease reviews. This presents an opportunity to explore doing things differently with your administrative team. At our practice, we used the return of full-scale chronic disease management to trial a birthday month-based recall system – something the nursing and admin teams were keen to try. There were many positive aspects, and I think it will help distribute workload and make things easier for patients, although the experience taught us that the busy flu campaign period – especially with the addition of Covid-19 vaccination – makes things tricky over winter. Another factor is non-responders; if you only invite a patient with a birthday in March, you won’t have time to reach out to non-attenders before the end of the QOF year. This year we are looking at a modified system where we invite April/May/June birthdays in April and May, aiming to get slightly ahead of the curve; we’ll see how it goes.

2: Use digital solutions to lighten your workload
Every primary care clinician is a precious resource. As there’s usually enough work to fill us all two or three times over, it’s vital to maximise clinical time for patients who need our skills the most. Using a variety of digital tools to support chronic disease processes allows us to deploy the nursing team efficiently and appropriately. Our integrated care board provides Accurx, although many other services perform similar functions.

A good example is asthma management. Patients are sent an Asthma Control Test (ACT) questionnaire and a video demonstrating inhaler techniques. Responses are screened by the admin team, who determine the next steps using a flowchart that includes ‘red flags’ to reduce clinical risk. Patients scoring 20 or higher (indicating good control) are booked into a short slot with the nurse or nurse associate, who can conduct a brief telephone call or respond via SMS. A score of 19 or lower triggers a longer appointment with the nurse, in person or by phone, depending on the patient’s preference.

The mantra is nursing time is precious and should be proportionate to patient need. Help from members of the wider team allows nurses more time for complex cases. 

3: Time to network
Primary care networks (PCNs) are now relatively mature structures with a significant workforce of staff recruited via the Additional Roles Reimbursement Scheme (ARRS). Many PCN teams will support practices with chronic disease management, so are you making the most of the opportunity to share the load with your local network team? Our excellent PCN pharmacist assists with atrial fibrillation and heart failure annual reviews at our practice. Those were the areas identified when we looked at where a pharmacist could be most effective, alongside COPD. They are centred around medication, and the help frees our nursing team to focus on other areas. Similarly, physician associates and nurse associates have skillsets that can offer valuable support. For example, our nurse associate conducts a range of reviews with housebound patients.

4: A smart approach for diabetes
Five years ago, we approached diabetes management with a one-size-fits-all method. It was effective, but incredibly time consuming. Unfortunately, time is something we never seem to have enough of in primary care — and our diabetes register is continually growing. We needed to get smarter about using our resources, and the PARM tool2 (a collaborative project between NHS Devon and pharma company Lilly) has proven to be a useful tool in our armoury. 

PARM stands for ProActive Diabetes Register Management, and is essentially a tool to identify patients who may benefit from medicines optimisation to improve HbA1c control as part of the QOF targets. It accounts for frailty and sorts patients based on the medications they are currently taking. Similar tools are coming online, and if you’re uncomfortable with the pharma link-up, you could create a series of searches and filters to identify patients who might benefit from a certain intervention. However, PARM is an effective tool to highlight areas of focus for your diabetes population.

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5: Childhood vaccination changes
This has been a subject of controversy in the world of QOF over the past two years. The upper and lower thresholds for the VI001, VI002 and VI003 domains were so challenging that many practices lost thousands of pounds, with those in areas of deprivation most affected. It has been consistently argued that this reinforced health inequalities but thankfully, there has been some movement and the new thresholds should see fewer practices left out of pocket.

An important new NHS England provision is that ‘children vaccinated overseas in accordance with the UK national schedule can be coded as a success for the purposes of QOF achievement’.3 If you work in an area of high immigration, this could have a transformative impact on achievement for these indicators, so a thorough vaccination history is imperative.

6: No room for rheumatoid arthritis?
RA002, the indicator for face-to-face reviews of patients with rheumatoid arthritis (RA), has been retired this year, so it is no longer a contractual requirement. It would be prudent to discuss at a practice level how you plan to proceed. RA patients may well be expecting an invite to review their condition so it will be important to communicate your practice’s decision. Options are to continue to do the reviews for all patients, offer a brief telephone review as a halfway house, or to inform patients that the reviews will no longer be happening routinely but to contact the surgery if they develop new symptoms or concerns.

7: Act on weight readings
How many patients step onto the scales as part of their chronic disease review? It’s a significant number. I work in an area of deprivation, with some of the highest obesity rates in the UK. A sizeable proportion of the adult patients I see are overweight or obese, yet I don’t feel I discuss weight-management options or make referrals anywhere near enough. It can be a taboo subject and a tricky one to broach, but as I discussed in a previous article, there is strong evidence that a brief intervention from a clinician can be effective.4 There is also the under-publicised Weight Management Enhanced Service⁵; find out if your practice should sign up and what the local options are.

8: Take a look at lipids
Cholesterol control and lipid management is a new focal point in the 2023/24 QOF year. Practices will have their own workflows for lipid management, with duties distributed between medical, nursing and pharmacy teams. There are 30 points available collectively for the new CHOL001 and CHOL002 indicators, which focus on prescription of a statin or equivalent and control (non-HDL cholesterol lower than 2.5 mmol/L or LDL <1.8 mmol/L). The control aspect is new, and these may be figures your practice hasn’t used before. They are drawn from the Joint British Societies’ recommendations.6

It would be advisable to conduct a practice-wide clinical meeting looking at lipid management to ensure everyone is on the same page and aware of the pathways and responsibilities. This is a big indicator and rightly so, as lipid control remains crucial in terms of primary and secondary prevention.

9: Cervical screening – consider extended access
Cervical screening applies to women and transgender men with a cervix aged between 25 to 64. These are people of working age, which can mean access is challenging during normal surgery hours. Consider using PCN extended-access arrangements to widen access opportunities to those who struggle to get time away from work. This reduces a barrier to access and can improve screening rates.

10. Workforce wellbeing – make it more than a tickbox exercise
This year sees the introduction of a quality improvement indicator on workforce wellbeing. This could wind up being a time-consuming tickbox exercise, but there is an opportunity to make it more meaningful. Your practice will be evaluating your wellbeing as part of the primary care workforce so think about what you’d like to see change – be it more flexible working options, improved communication within the practice or better training for new staff members – and provide honest and constructive feedback. Nursing teams have a fantastic oversight of how a practice functions and GP partners and managers should value and respect your opinions. 

Dr David Coleman is a GP partner and co-clinical director at Doncaster South PCN, South Yorkshire


  1.  NHS Confederation. GP Contract changes 2023/24: what you need to know. 2023. Link
  2.  PARM Diabetes. parmdiabetes.co.uk
  3.  BMA. Quality and outcomes framework. Updated April 2023. Link
  4.  Aveyard P et al. Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. Lancet 2016;388:2492-500. Link
  5.  NHSE. Weight Management Enhanced Service 2023/24. Link
  6.  JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease. Heart 2014;100:ii1-ii67. Link



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