The CDRC includes a full suite of resources to support the Impact and Investment Fund (IIF)
These reports and templates are available to all units that are a member of the DCS group.
Additional resources are available (such as pop-ups, patient status alerts and other alerts) to units who wish to opt-in. These resources will make it much easier to achieve the IIF targets.
Prevention and Tackling Health Inequalities
Vaccination and Immunisation
Percentage of patients aged 65 or over who received a seasonal influenza vaccination between 1st September and 31st March in current flu season
Payment range 80-86%
Payment also depends on number of patients aged 65+ without an exception
Use the Influenza Vaccination system to target patients for vaccination
Performance and work to do searches can be found here:
Patients in the bottom search are those people who have been invited twice but not yet vaccinated. They will not appear in the denominator for the indicator until they are vaccinated.
Percentage of patients aged 18 to 64 years and in a clinical at-risk group who received a seasonal influenza vaccination between 1st September and 31st March in current flu season
Payment range 57-90%
Payment also depends on number of patients aged 18-64, at risk, without an exception
Use the Influenza Vaccination system to target patients for vaccination
Performance and work to do searches can be found here:
Patients in the bottom search are those people who have been invited twice but not yet vaccinated. They will not appear in the denominator for the indicator until they are vaccinated.
Percentage of patients aged two or three years on 31 August 2022 who received a seasonal influenza vaccination between 1st September and 31st March in current flu season
Payment range 45-82%
Payment also depends on number of patients aged 2-3 on 1st September, without an exception
Use the Influenza Vaccination system to target patients for vaccination
Performance and work to do searches can be found here:
Patients in the bottom search are those people who have been invited twice but not yet vaccinated. They will not appear in the denominator for the indicator until they are vaccinated.
Tackling Health Inequalities
Percentage of patients on the QOF Learning Disability register aged 14 or over, who received an annual Learning Disability Health Check and have a completed Health Action Plan.
Payment range 60-80%
Payment also depends on number of patients aged 18+ with LD without an exception
Use the Learning Disabilities system to complete the review and care plan.
Performance and work to do searches can be found here (End of Year and How Am I Driving):
Patients in the bottom 1.1 searches are those people who have been exception reported in the current year. They would add to performance and payment if review and health check were completed.
Tips to Achieve This Indicator
Patients in the bottom 1.1 searches are those people who have been exception reported in the current year. They would add to performance and payment if review and health check were completed.
Percentage of registered patients with a recording of ethnicity on their GP record
Payment range 81-95%
Payment also depends on list size.
Recording that a patient does not want to state their ethnicity ‘counts’.
Patients who need an ethnicity recording will be flagged on the home screen, with a link to the ethnicity recording template (opt-in needed)
More usefully, patients can be bulk sent a questionnaire to complete online.
Show the patients from the ‘work to do’ search
Use the communications annexe option to bulk send a message
Create a communication annexe like this, adding the Ethnicity questionnaire (you could create a preset to use again in future):
This text can be copied and pasted into the message
Dear <forename> <surname>
We would be very grateful if you could use this link to let us know your ethnicity
Regards
<staff_member_title> <staff_member_forename> <staff_member_surname>
Click send
Replies will come back as tasks to the person who sent the message. Action the task to record the information.
Performance and work to do searches can be found here:
CVD Prevention
Percentage of patients aged 18 or over with an elevated blood pressure reading (≥140/90mmHg) and not on the QOF Hypertension Register, for whom there is evidence of clinically appropriate follow-up to confirm or exclude a diagnosis of hypertension.
Payment range is 25-50%
Payment also depends on the number of people in the denominator of the indicator.
This is a very complex indicator which is designed to help detect new hypertension. The denominator consists of people:
- whose last BP in the 2 years before the current financial year was >=140/90
- OR
- Have a BP >=140/90 in the current year
There are multiple ways to achieve the indicator, but the easiest way to do this is to record a home or ambulatory blood pressure.
Action on this indicator will help to achieve CVD-02.
Patients who need a BP check will be flagged (opt-in needed) on the home screen, with a link to the IIF template:
Performance and patient identification searches can be found here:
Patients can be invited (by electronic or other means) to:
- Have a blood pressure checked at the surgery
- Purchase their own BP machine to use at home
- Attend a local pharmacy which is taking part in the hypertension case finding project.
Percentage of registered patients on the QOF Hypertension Register
Payment range – Hypertension prevalence to be 0.4 – 0.8 percentage points greater than 2021/22 year end (these thresholds were lowered mid-year in September 2022).
Payments also depend on the overall hypertension prevalence.
Because of the relatively high death rate among people with hypertension, practices will need to diagnose around 1.4% of the list with new hypertension
For resources on detecting new or un-coded hypertension other resources are available here Detecting Hypertension
The following searches will give an idea of progress. The figures for the previous year are an estimate. Exact data can be found from the last QoF submission.
Percentage of patients aged between 25 and 84 years inclusive and with a CVD risk score (QRISK2 or 3) >20%, who are currently treated with statins
Patients who need to consider statin treatment will be flagged (opt-in needed) on the home screen and the demographic box, with a link to the IIF template
The IIF template has a link to the Lipid template if lipid lowering therapy is to be considered.
Options for exceptions are shown at the bottom of the screen.
Performance and patient identification searches can be found here, CDRC Contracting > PCN DES:
Tips For Achieving This Indicator
Search 3.2 identifies eligible people who have declined in previous years. It might be worth asking these patients again. Many will decline again providing a rapid way to reduce the denominator size (but NB the size of the denominator also affects payment).
Percentage of patients aged 29 and under with a total cholesterol >7.5 OR aged 30 and over with a total cholesterol >9.0 who have been either:
- Assessed for possible familial hypercholesterolaemia e.g. using the Dutch Lipid Clinic Network score
- referred for assessment for familial hypercholesterolaemia
- Diagnosed with genetic FH
- Diagnosed with secondary hyperlipidaemia
Patients who need consideration for FH testing will be flagged (opt-in needed) on the home screen, with a link to the IIF template.
The following searches will identify relevant patients, CDRC Contracting > PCN DES:
Tips For Achieving This Indicator
- First run searches 4.1 and 4.2 to correct potential coding errors.
4.1 – Identifies patients who have been referred to or seen in a lipid clinic in the past using a code that is not recognised by these business rules such as ‘seen in lipid clinic’. Record the business rules code Referral for FH assessment shown on the template above if appropriate.
4.2 – Identifies patients who have a diagnosis of FH or possible/probable FH who do not have one of the genetic FH codes recognised by the business rules. Review the record. Consider adding a genetic diagnosis code if the patient has had a genetic test or consider referral to confirm a genetic diagnosis. Remove the code if the patient doesn’t have FH.
- Next, check remaining patients in the ‘work to do’ search and retrospectively add ‘Referral for FH assessment’ to any patients who have previously been referred to a lipid clinic or other relevant service.
- The cholesterol >9/>7.5 is quite non-specific and insensitive for detection of AF. Many of these patients will not need referral to a lipid clinic and the majority will have a secondary cause of hyperlipidaemia such as diabetes, obesity, alcohol excess, antipsychotic use. Probably only about 10% of the patients in the >9/>7.5 cohort will have FH and many patients with FH will be missed. Two of the searches help to focus work on the patients more likely to have FH and those more likely to have secondary hyperlipidaemia:
- 4.3 – Identifies patients eligible for IIF FH referral who are at higher risk of having FH – review these patients and consider referral.
- 4.4 – Identifies patients eligible for IIF FH referral who are likely to have a secondary cause of FH – review these patients – many could be coded with secondary hyperlipidaemia.
Further guidance for lipid result interpretation can be found here Aetiology of Abnormal Lipids
Percentage of patients with AF and a CHA2DS2-VASc score of >=2 (>=1 if not female) who are prescribed a DOAC, or, if a DOAC is declined or unsuitable, a Vitamin K antagonist.
Patients who need to consider anticoagulation will be flagged (opt-in needed) on the home screen and the demographic box, with a link to the IIF template.
The template has links to the Atrial Fibrillation and Anticoagulation templates
Performance and Work-to-do searches are available:
Number of patients that are currently prescribed Edoxaban, as a percentage of patients with AF with a CHA2DS2-VASc >=2 (>=1 if not female) and who are currently prescribed a DOAC.
Patients who need to consider switch to edoxaban will be flagged (opt-in needed) on the home screen and the demographic box, with a link to the IIF template.
The template has a link to the Anticoagulation template
Performance and Work-to-do searches are available, CDRC Contracting > PCN DES:
The work to do search is subdivided into patients whose last CG CrCl is above and below 95. Edoxaban is not normally recommended for people with a creatinine clearance >95.
Providing High Quality Care
Personalised Care
Percentage of registered patients referred to a social prescribing service
Payment thresholds are 0.8 – 1.2% of the population having a referral each year (these thresholds were reduced mid-year in September 2022)
A performance search is available
Enhanced Health in Care Home
Number of patients aged 18 years or over and recorded as living in a care home, as a percentage of care home beds aligned to the PCN and eligible to receive the Network Contract DES Enhanced Health in Care Homes service
To achieve this indicator, ensure that all patients living in a care home are coded as care home residents.
The following search identifies patients who are currently coded as living in a care home.
Percentage of care home residents aged 18 years or over, who had a Personalised Care and Support Plan (PCSP) agreed or reviewed
Patients who need to consider statin treatment will be flagged (opt-in needed) on the home screen and the demographic box, with a link to the IIF template
The IIF template links to the Comprehensive Geriatric Assessment to allow completion of a PCSP
The following searches identify care home patients with and without a personalised care and support plan, CDRC Contracting > PCN DES:
Mean number of patient contacts as part of weekly care home round per care home resident aged 18 years or over.
Data is extracted from the practice address book by NHS England looking at slots with the Weekly Care Home Round slot type.
Standardised number of emergency admissions on or after 1 October per care home resident aged 18 years or over. Data will be extracted from hospital systems.
SUSPENDED FOR 2022/23
Anticipatory Care
Cancer
Percentage of lower gastrointestinal two week wait (fast track) cancer referrals accompanied by a faecal immunochemical test result, with the result recorded either in the 21 days * leading up to the referral, or in the 14 days after the referral
*THIS INDICATOR WAS AMENDED MID YEAR IN SEPTEMBER 2022 FROM 7 DAYS TO 21 DAYS.
The relevant information is shown on the CAN-01 tab of the IIF template.
Access
Structured Medication Reviews and Medicines Optimisation
Percentage of patients at risk of harm due to medication errors who received a Structured Medication Review
SMRs are required for patients with the following medication issues:
- Over 65y with NSAID prescription without gastroprotection in the 3 months before each NSAID script
- NSAID with any prior GI bleeding or peptic ulcer
- Antiplatelet with any prior GI bleeding or peptic ulcer
- Aspirin and another antiplatelet within 28d of each other
- Antiplatelet and anticoagulant with 28d of each other
- NSAID and anticoagulant within 3m of each other
- NSAID and heart failure
- NSAID with a prior eGFR <45
- Non-selective betablocker and asthma
Patients who need consideration for SMR-01A will be flagged (opt-in needed) on the home screen and demographics box, with a link to the IIF template
The template will display the reason the patient is on the high risk list.
The Show Scripts buttons can be used to see more detailed information e.g. the patient below was on dual antiplatelet following PCI and this has now stopped.
An opt-in prompt will trigger if a patient in the SMR-01A group has a (non-structured) medication review, prompting the user to consider upgrading this to an SMR.
Performance and work-to-do searches are available for both ‘end of year’ and ‘how am I driving’ periods. Use of the HAID reports during the early part of the year will prevent people being invited for early, unecessary repeat SMR, if an SMR was done later in the previous year.
Percentage of patients living with severe frailty who received a Structured Medication Review
SMRs are required for patients with severe frailty (*see note about severe frailty)
Patients who need consideration for SMR-01B will be flagged (opt-in needed) on the home screen and demographics box, with a link to the IIF template
An opt-in prompt will trigger if a patient in the SMR-02B group has a (non-structured) medication review, prompting the user to consider upgrading this to an SMR.
Performance and work-to-do searches are available for both ‘end of year’ and ‘how am I driving’ periods. Use of the HAID reports during the early part of the year will prevent people being invited for early, unnecessary repeat SMR, if an SMR was done later in the previous year.
The B.1 searches identify those people eligible for an SMR who have already had a (non-structured) medication review in the current year.
The B.2 search identifies people who are excepted but would still be eligible for an SMR. An SMR in these patients would increase the numerator and denominator, increasing payments. These patients will usually be palliative care patients (as the majority of severely frail patients are) who may well benefit from an SMR.
* Definition of Severe Frailty
NHS England have made an error in the business rules definition of severe frailty. As well as including the frailty Snomed codes and some Rockwood codes, they have also included eFI score above 0.36. This is completely inappropriate because the majority of people with such a score do not have severe frailty. If your unit batch added eFI scores, this may lead to a very large ‘severe frailty denominator’. NHS England have been informed of this problem.
Percentage of patients using potentially addictive medicines who received a Structured Medication Review
SMRs are required for patients with the following medication issues:
- All patients
- Benzodiazepines/Z drugs and gabapentinoids (<3m apart)
- Patients without a cancer code in the last 6 months
- Benzodiazepines/Z drugs and strong opioids (<3m apart)
- Gabapentinoids and strong opioids (<3m apart)
- Repeated issues of any of the drugs above (e.g. >=2 issues in a three month period)
- Any issue of very strong opioids
Strong opioids are defines as virtually all opioids apart from codeine and dihydrocodeine
Very strong opioids include the following daily doses of:
- Morphine >=60mg
- Oxycodone >=40mg
- Fentanyl >=50mcg patches
- Buprenorphine >=52.5mcg patches
Patients who need consideration for SMR-01C will be flagged (opt-in needed) on the home screen and demographics box, with a link to the IIF template
The template will display the reason the patient is on the addictive medicines list.
An opt-in prompt will trigger if a patient in the SMR-01C group has a (non-structured) medication review, prompting the user to consider upgrading this to an SMR.
Performance and work-to-do searches are available for both ‘end of year’ and ‘how am I driving’ periods. Use of the HAID reports during the early part of the year will prevent people being invited for early, unecessary repeat SMR, if an SMR was done later in the previous year.
Percentage of permanent care home residents aged 18 years or over who received a Structured Medication Review.
Patients who need consideration for SMR-01D will be flagged (opt-in needed) on the home screen and demographics box, with a link to the IIF template.
An opt-in prompt will trigger if a patient in the SMR-02D group has a (non-structured) medication review, prompting the user to consider upgrading this to an SMR.
Performance and work-to-do searches are available for both ‘end of year’ and ‘how am I driving’ periods. Use of the HAID reports during the early part of the year will prevent people being invited for early, unnecessary repeat SMR, if an SMR was done later in the previous year.
Percentage of patients aged 18 years or over prescribed both a NSAID and an oral anticoagulant in the last three months of the previous financial year, who in the three months to the reporting period end date were either:
- (i) no longer prescribed an NSAID or
- (ii) prescribed a gastroprotective in addition to both an NSAID and an oral anticoagulant
Patients who need consideration for SMR-02A will be flagged (opt-in needed) on the home screen and demographics box with an SMR-02 warning, with a link to the IIF template
The template will show the relevant medications.
Performance and Work-to-do searches are available. The EOY searches will only be useful in the final three months of the financial year.
Tip For Achieving This Indicator
Use the HAID reports until the last 3 months of the financial year.
Percentage of patients aged 65 years or over prescribed an NSAID (but not an oral anticoagulant) in the last three months of the previous financial year, who in the three months to the reporting period end date were either:
- (i) no longer prescribed an NSAID or
- (ii) prescribed a gastroprotective in addition to an NSAID
Patients who need consideration for SMR-02B will be flagged (opt-in needed) on the home screen and demographics box with an SMR-02 warning, with a link to the IIF template
The template will show the relevant medications.
Performance and Work-to-do searches are available. The EOY searches will only be useful in the final three months of the financial year.
Tip For Achieving This Indicator
Use the HAID reports until the last 3 months of the financial year.
Percentage of patients aged >=18 years prescribed both an oral anticoagulant and an anti-platelet in the last three months of the previous financial year, who in the three months to the reporting period end date were either:
- (i) no longer prescribed an anti-platelet or
- (ii) prescribed a gastroprotective in addition to both an oral anticoagulant and an anti-platelet
Patients who need consideration for SMR-02C will be flagged (opt-in needed) on the home screen and demographics box with an SMR-02 warning, with a link to the IIF template
The template will show the relevant medications.
Performance and Work-to-do searches are available. The EOY searches will only be useful in the final three months of the financial year.
Tip For Achieving This Indicator
Use the HAID reports until the last 3 months of the financial year.
Percentage of patients aged 18 years or over prescribed aspirin and another anti-platelet in the last three months of the previous financial year, who in the three months to the reporting period end date were either:
- (i) no longer prescribed aspirin and/or no longer prescribed an anti-platelet or
- (ii) prescribed a gastroprotective in addition to both aspirin and another anti-platelet
Patients who need consideration for SMR-02D will be flagged (opt-in needed) on the home screen and demographics box with an SMR-02 warning, with a link to the IIF template
The template will show the relevant medications.
Performance and Work-to-do searches are available. The EOY searches will only be useful in the final three months of the financial year.
Tip For Achieving This Indicator
Use the HAID reports until the last 3 months of the financial year.
Percentage of patients prescribed a DOAC, who received a renal function test AND have a wight recording AND Cockcroft Gault creatinine clearance, along with a code for DOAC dose changed / unchanged
Patients who need consideration for SMR-03 will be flagged (opt-in needed) on the home screen and demographics box with an SMR-03 warning, with a link to the IIF template. The alert explains which information is missing.
The detailed dose information button will link to the relevant anticoagulation page showing dosing information
Performance and work to do searches are available
Automatic Alerts To Help
Achieving this indicator is difficult because the rules are so complex. The CG CrCl must be recorded on or after the date of the first eGFR of the financial year.
The weight must be in the period after 12 months before this first CG CrCl AND ALSO before the last CG CrCl in the current year.
The ‘dose changed/unchanged’ code must be on or after first CG CrCl recorded after the first eGFR in the financial year.
To help get around this problem the IIF opt-in alerts include an automatic alert which will trigger if a CG CrCl value is added to remind the user to record if the dose is changed/unchanged.
An addition alert is available which will prompt the user to record the CG CrCl when filing relevant creatinine results from the pathology inbox. THIS FUNCTION IS ONLY AVAILABLE TO PRACTICES WHICH HAVE ASKED TPP TO ENABLE THE AUTO-FILING FUNCTION.
Respiratory Care
Percentage of patients on the QOF Asthma Register who received three or more inhaled corticosteroid (ICS, inclusive of ICS/LABA) prescriptions over the previous 12 months
The IIF template will show the ICS issues from the last year
The Asthma template will also show the IIF issues alongside other safety and quality prompts.
These searches will identify achieved and unachieved patients. The end of year searches will only become accurate towards the end of the year. Use the HAID searches earlier in the year
NB there is a fault in the business rules which means that patients with COPD and asthma taking inhalers with ICS licensed for COPD (such as trelegy or trimbow) are not counted. NHSE are aware of this flaw and have said they will amend it.
Tips For Achieving This Indicator
- Review the unachieved patients with asthma and COPD.
- For patients on COPD ICS inhalers such as trelegy – hopefully this will be fixed in the business rules before the end of the year
- For patients not on ICS inhalers, consider whether the asthma diagnosis is still relevant:
- If the patient never had asthma – mark the asthma diagnosis ‘in error’
- If the patient no longer has asthma (i.e. not asthma/COPD overlap) code asthma resolved at the appropriate time.
- Consider exception coding people with mild asthma and low SABA. The search which looks for low SABA use will identify unachieved patients with low SABA use who might be suitable for coding as ‘Mild asthma’ AND ‘ICS not indicated’ This can be done on the IIF template or the Asthma template.
RESP-02: Percentage of patients on the QOF Asthma Register (but without COPD) who received >=6 SABA inhaler prescriptions over the previous 12 months
These searches will identify achieved and unachieved patients. The end of year searches will only become accurate towards the end of the year.
Unlike most of the IIF searches, the people appearing in the payment search are the people who have not achieved the recommended outcome i.e. <6 SABA prescriptions in a year. For this reason the performance search is also the work to do search.
NB – The business rules for these searches counts prescriptions NOT inhalers. A patient having 4 prescriptions for 8 inhalers in 12 months would achieve the indicator.
Tips For Achieving This Indicator
- Consider whether high using patients have COPD (either as asthma/COPD overlap or COPD alone). Coding the patient with COPD will remove them from the denominator
Sustainable NHS
Environmental Sustainability
Metered Dose Inhaler (MDI) prescriptions as a percentage of all non-salbutamol inhaler prescriptions issued to patients aged 12 years or over
This indicator rewards switching patients from MDI inhalers to dry powder inhalers. Slightly bizarrely, it includes all long acting inhalers AND terbutaline (bricanyl).
This information will be shown on relevant LTC templates
The data for this indicator is extracted from prescribing authority reports. This data is difficult to extract directly from clinical systems.
These searches will:
- Identify patients to consider switching inhalers
- Give an estimate of performance
To get an estimate of performance, breakdown the results using these two breakdown options. Then use the item count figures from 1.1 and 1.2 to calculate the percentage.
Tips For Achieving This Indicator
- Identify patients to consider for switching during LTC reviews
- Identify patients to switch using the searches – consider approaching them directly.
- NB Switching patients from salbutamol MDI to terbutaline DPI will add them to the numerator and denominator of ES-01, whilst removing them from the denominator of ES-02
Mean carbon emissions per salbutamol inhaler prescribed (kg CO2e)
This indicator rewards switching people from salbutamol inhalers with a high environmental impact to a lower one. The data for this indicator is extract from the prescribing authority and counts the total number of inhalers. This can be difficult to extract directly from clinical systems as it is hard to differentiate prescriptions for a single or multiple inhalers.
Slightly bizarrely, terbutaline (bricanyl) is not counted in this indicator. It is counted in the ES-01 indicator with all the long acting inhalers. So switching a patient from a high impact salbutamol inhaler to bricanyl will improve ES01 and ES02 performance.
Relevant information is shown on LTC templates
| Inhaler | Kg/CO2e |
| Ventolin Accuhaler 200 microgram | 0.58 |
| Easyhaler Salbutamol 100 microgram | 0.62 |
| Easyhaler Salbutamol 200 microgram | 0.62 |
| Salbulin Novolizer 100 microgram | 3.75 |
| Airomir 100 microgram | 9.72 |
| Airomir Autohaler 100 microgram | 9.72 |
| Salbutamol CFC free breath actuated inhaler 100 microgram (GENERIC) | 11.79 |
| Salamol CFC-Free Inhaler 100 microgram | 11.95 |
| Salamol Easi-Breathe 100 microgram | 12.08 |
| Salbutamol CFC free Inhaler 100 microgram (GENERIC) | 25.24 |
| Ventolin Evohaler 100 microgram | 28.26 |
The bricanyl (terbutaline) DPI also has a very low carbon impact but see notes about impact on indicator performance above.
Practice performance can be monitored on Openprescribing in the respiratory section https://openprescribing.net/ but this data has quite a time lag.
To obtain an estimate of performance from practice data, use the following 3 breakdown options for the 4.2 search then order the data by practice.
Then click on the csv button to extract the data.
Highlight the data from your practice
Right click on the spreadsheet below and download a copy to your computer:
Paste your data into the new spreadsheet – an estimated CO2 equivalent figure will be shown in cell H2
Opting In To Additional Resources
Opt-in resources include patient status alerts (icons) to flag patients with IIF issues and automatic prompts to ensure the correct information is coded at the appropriate time.
To opt in to the additional resources email NECSU.CDRC@nhs.net
You can see if resources are enabled by checking the search below. If this search returns a similar number to your list size, the suite of resources are enabled. You can disable individual resources in the usual way.
If the search returns a number which is significantly different from your list size contact the helpdesk on the email above.
- Protocol which runs when renal function results are filed to prompt recording of CG CrCl.