One of the items that CQC will review with practices on inspections is the QOF exception rates. The data for these is available from NHS Digital where you can search by practice and look at historical QOF data, including exception rates.
Practices have recently contacted our support desk following a CQC inspection asking why their exception rates are so high, particularly for cancer clinical indicators. In the example above the practice had not recorded any exceptions for cancer patients in that year so how does that equate to an exception rate of 26.5%?
Practices can also run QOF achievement reports in CQRS and extract exception / exclusion data.
Again, in the example above, from the same practice, you can see that it doesn't appear that there were no exceptions recorded that year yet the exception rate is showing as 26.52%
2. Exclusion that are Exceptions?
Having communicated with NHS Digital it transpires that there is a misconception of what are exceptions and what are exclusions. Exclusions are normally for reasons that are beyond the control of the practice whereas an exception is a result of something that has been recorded by the practice. Exception rates are used as a quality measure of the practice.
Many indicators have business rules to identify either newly registered or newly diagnosed patients.
Example - CAN003: Patients diagnosed in the 6 months before the 'Payment Period End Date' (PPED)
In the CQRS data screen shot above you will see there were 35 patients diagnosed with cancer in the 6 months leading up to the end of the QOF year. These patients would have been filtered out by the QOF business rules and would not have had an alert in the QOF alert box. At the end of the QOF year, if they have not had a review, these patients are automatically excepted from the Cancer QOF targets and are used in the practice exception rate calculation and this is why you may end up with a high exception rate without realising.
In addition, the 2019/20 QOF business rules include new 'Personalised Care Adjustments'. These have added automatic exceptions where a patient has had two invites, more than 7 days apart, coded with the correct QOF invite codes and have not had a review coded. According to NHS digital these patients will also count as ‘excepted’ so potentially practices could end up with very high exception rates this year.
NHS Digital’s logic in both cases above, either when a patient is diagnosed towards the end of the QOF year or has two invites, is that these are patients that could be reviewed and the necessary work completed. Therefore, if you don't, then they are classed as exceptions.
3. How to avoid this situation
3.a Excluded patients
EMIS mix together ‘Exclusions’ and ‘Exceptions’ which makes it very difficult to identify patients who are going to count towards your exception rates. We are developing searches which will help to make this clear for you. Please note - Any QOF work completed over-rides an exception (whether that be exception due to addition of a code, due to 2 invites or due to recent diagnosis or registration) and does count towards end of year achievements.
3.b Two QOF invites and no review
We have recently released some reports to help practices identify patients who have had two QOF invites coded more than 7 days apart and still have outstanding QOF work. These can be found in 'Population Reporting > Ardens-QMasters > Ardens-QMasters QOF Catcher'
A process should be in place to regularly monitor the 'Excluded Patients'. Any QOF work completed overrides an exclusion or exception and does count towards the practice end of year achievements.