1. Background

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 a QOF alert showing on the patient home screen therefore the clinician seeing the patient would be unaware that a review is outstanding. 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 thisis why you may end up with a high exception rate without realising.


In addition for 2019/20 the QOF business rules include 'Personalised Care Adjustments' where a patient who has had two invites more than 7 days apart, coded with the QOF invite codes and no review coded is automatically removed from the QOF indicator/s. According to NHS digital these will also count as an exception so potentially unless you are proactive practices could have very high exception rates this year. 


In both cases above, when a patient is diagnosed towards the end of the QOF year or has two invites, these are patients that you can still get in and complete the necessary work even though there will be no QOF alerts. if you don't, then they are classed as exceptions. 


3. How to avoid this situation

3.a Excluded patients

In SystmOne you can review this years lists of 'excluded' patients by going to 'Reporting > QOF Indicators > Excluded Patients'.

Sticking with cancer, you can see that this year there are 22 patients so far who have been diagnosed, if no action is taken before the end of the QOF year, these will count as exceptions and you will have a high exception rate.


3.b Two QOF invites and no review

TPP Have 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 'System Wide > QOF 2019 to 2020 v44 > xx Invitation status alerts xx'

These patients will have a duplicate QOF symbol to the very left of all patient status alert symbols and if you put your cursor over the symbol it will tell you the patient has been excluded because they have had two invites


3.c Monitoring 

Just as practices regularly review the 'QOF Points > End of Year'  data, 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.