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Designed and developed in the North East and North Cumbria by local GPs

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You are here: Home / Resources / SystmOne Resource Centre / Contract Management / Impact and Investment Fund (IIF)

Impact and Investment Fund (IIF)

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

VI-01 Influenza Vaccination 65+

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: 

Asthma (33) 
Automatic immunisation messaging (I ) 
CORC (S8S8) 
CORC contracting (33S) 
PCNOES(117) 
aoF (194) 
• Time Limned Indicators (2) 
Vaccines (8) 
Preventing and tackling health inequalities 
1 Influenza Vaccination 
1 VI-Ol- 
65ft Influenza vaccine - Achievement (Payment range 80-86%) 
1 VI-Ol- 
65ft Influenza vaccine - Work to do 
!IIF Tl VI-Ol- 
655* Influenza vaccine - Work to do (including invited but not vaccinated) 
1 VI-02 
- 18-64y at risk - Influenza vaccine - Achievement (Payment range 57-90%) 
1 VI-02 
- 18-64y at risk- Influenza vaccine - Work to do

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. 

VI-02 Influenza Vaccine 18-64y at risk

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: 

Automatic immunisation messaging (I ) 
CORC (S8S8) 
CORC contracting (335) 
PCNOES(117) 
aoF (194) 
• Time Limned Indicators (2) 
• Vaccines (8) 
• Weight Management (18) 
CORC Groups (2492) 
Preventing and tackling health inequalities 
Influenza Vaccination 
VI-Ol- 
65ft Influenza vaccine - Achievement (Payment range 80-86%) 
VI-Ol- 
65ft Influenza vaccine - Work to do 
VI-Ol- 
65ft Influenza vaccine - Work to do (including invited Out not vaccinated) 
1 VI-02- 18-64 at risk- Influenza vaccine-Achievement Pa ment ran e 57-90% 
VI-02 
- 18-64y at risk- Influenza vaccine - Work to do 
VI-02- 18-64y at risk- Influenza vaccine- Work to do (including invited butnotvaccinated) 
VI-03 
- 2-3y - Influenza vaccine - Achievement (Payment range 45-82%)

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. 

VI-03 Influenza Vaccine 2-3y

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: 

CORC contracting (335) 
PCNDES(117) 
aoF (194) 
• Time Limited Indicators (2) 
VI-02- 18-64y at risk- Influenza vaccine - Work to do 
VI-02 
- 18-64y at risk - Influenza vaccine - Work to do (including invited but not vaccinated) 
1 VI-03 
-2-3 -Influenza vaccine-Achievement Pa ment ran e45-82% 
VI-03 
-2-3y- Influenza vaccine - Work to do 
!IIF Tl VI-03 
- 2-3y - Influenza vaccine - Work to do (including invited but not vaccinated) 
2 
Learning Disability Checks

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

HI-01 Learning Disability Health Check and Action Plan 

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): 

CORC contracting (20S) 
(148) 
aoF (33) 
• Time L mited Indicators (2) 
• Vaccines (8) 
• Weight Management (18) 
CORC Groups (03) 
CORC Medicines (28) 
CORC Performance (223) 
1 VI-02 
1 VI-03 
1 VI-03 
1 VI-03 
- 18-64y at risk - Influenza vaccine - Work to do (including invited but not vaccinated) 
- 2-3y - Influenza vaccine - Achievement (Payment range 45-82%) 
-2-3y - Influenza vaccine - Work to do 
-2-3y - Influenza vaccine - Work to do (including invited Out not vaccinated) 
2 Learnin Disabili Checks 
2 Hl- 01 - Learning Disability Health Check and Action Plan - EOY Achievement (Payment range 60-80%) 
2 Hl- 01 - Learning Disability Health Check and Action Plan - EOY Work to do 
2 Hl- 01 - Learning Disability Health Check and Action Plan - EOY Currently excepted 
2 HI-Ol - Learning Disability Health Check and Action Plan - HAD Achievement (Payment range 60-80%) 
2 HI-Ol - Learning Disability Health Check and Action Plan - HAD work to do 
2 HI-OTI - Learning Disability Health Check and Action Plan - HAD Currently excepted 
3 Ethnicitv Recordina

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. 

HI-02 Ethnicity Recording

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) 

'IF Record Ethnicity: Please record ethnicity 
Action More 
Missing demographics for sharing verification 
Action More 
Online Services: Not Using Online Services 
Action More

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 

Use the Communications Annexe to send the selected patients a communication

Create a communication annexe like this, adding the Ethnicity questionnaire (you could create a preset to use again in future): 

Preferred contact method 
SMS consent 
- Message 
send SMS 
Letter 
Consent recorded 
Allow patie nt to repty 
ear <forename> <surname> 
We would be very grateful If you could use this link to letus 
know your ethnicity 
- Preview 
Dear Nic-Donotuse Mestpatientkamb 
We would be very grateful ifyou could use this link to let us 
know your ethnicity 
Regards

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: 

-UI - Learning DisaOlllty Healtn cnecK ano Action Plan - Acmevement (Payment rang 
Arfans searches (I 
2 HI-Ol - Learning Disability Health Check and Action Plan - Work to do 
2 HI-Ol - Learning Disability Health Check and Action Plan - Currently excepted 
CORC (3945) 
3 Ethnici Recordin 
CORC contracting (175) 
3 HI-02 Ethnicity Recording - Achievement (Payment range 81-95%) 
PCNOES (118) 
aoF (33) 
• Time Limned Indicators (2) 
Vaccines (8) 
! IIFI 
a HI-02 Ethnicity Recording - Work to do 
4 CVO Prevention 
4 CVO-OI - Raised BP - appropriately managed - Achievement (Payment Range 25- 
4 CVO-OI - Raised BP - appropriately managed - Work to do

CVD Prevention

CVD-01 Raised BP

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:  

'IF CVD-OI Consider hypertension: Please consider new hypertension 
Action More 
Missing demographics for sharing verification Action More
CVD-OI 
Previous Page Home Next Page 
Percentage of patients 185* with BP 2140/90 and not on the OOF Hypertension Register, with evidence of appropriate follow-up to confirm or exclude hypertension 
Payment range 25-50% Payment size also determined by number of people in the denominator high readings 
Denominator 
(i) Last BP in previous 2 years E140/go 
(ii) BP in this year E140/go 
Excluding those With hypertension before the 
stan of the current year 
Achievement Routes 
For those in (i) - first BP in current year is <140/go 
systolic BP 
08 Dec 201g 
18 Dec 2019 
20 Jan 2020 
02 Mar 2021 
05 May 2021 
17 May 2021 
O/E- Systolic BP ren 
O/E- Systolic BP ren 
O/E- Systolic BP re 
O/E- Systolic BP ren 
O/E- Systolic BP ren 
O/E - Systolic BP ren 
Medication 
18C 
136 
132 
16Ü 
14Ü 
Diastolic BP 
08Dec201g 
18 Dec201g 
20 Jan 2020 
02 Mar 2021 
05 May2021 
17 May 2021 
O/E- Diastolic BP re 
O/E- Diastolic BP ren84 
O/E- Diastolic BP re 
78 m 
O/E- Diastolic BP re 
78 
O/E- Diastolic BP re 
O/E - Diastolic BP ren 
85 
Not on the palliative care register 
Show more 
Ambulatory ap 
Average home ap 
mmHg 
mmH g 
3. 
4. 
5. 
6. 
7. 
Medication changed and subsequent BP <140/90 
Diagnosed with hypertension and antihypertensive started 
Diagnosed with hypertension and Hypertension treatment refused 
Diagnosed with hypertension and Urgent referral (same date as high ap) 
Exceptions 
Add to palliative care list 
2. Home/A3PM Declined

Performance and patient identification searches can be found here: 

CORC contracting (175) 
(118) 
aoF (33) 
3 HI-02 Ethnicity Recording - Work to do 
4 CVO Prevention 
4 CVD-OI 
4 CVD-OI 
4 cvo-02 
- Raised8P-a ro riatel mana ed-Achievement a ment Ran 
- Raised BP - appropriately managed - Work to do 
- Hvoertension Prevalence 1 - End of 2020/21 (estimate) 
e 25-50%

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. 
CVD-02 Hypertension Prevalence

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. 

CORC contracting (175) 
PCNOES (118) 
aoF (33) 
• Time Limited Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
3 HI-02 Ethnicity Recording - Work to do 
4 CVO Prevention 
4 cvo-01 
- Raised BP - appropriately managed - Achievement (Payment Range 25-50%) 
4 cvo-01 
- Raised BP - appropriately managed- Work to do 
4 CVO-02-H elension Prevalence 1 - End of 2020/21 estimate 
4 cvo-02 
- Hypertension Prevalence 2 - End of 2021/22 (estimate) 
4 CVD-02 - Hypertension Prevalence 3 - Current (Must be 116-1 2% higher than last year)
CVD-03 25-84y QRISK >=20% on statin 

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  

'IF CVD-03 consider statin as QRISK 
Consider statin as

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. 

CVD-03 
Previous Page Home Next Page 
Percentage of patients aged 25-84y inclusive and With a CVD risk score (QRlSK2 or 3) who are currently treated with statins 
NB- other lipid lowering therapies dont count - such patients would need to be excepted 
Payment range 48-58% Payment size also determined Oy number of people without CVO with QRISK 
0 ll Lipids Management 
Exceptions 
2. 
3. 
4. 
5. 
6. 
Add to palliative care list 
Patient on maximal tolerated lipid lowering therapy (in current year) 
Statin contraindications (current year) 
Statin contra-indications (ever) 
Statin not tolerated (ever) 
Statin declined (ever)

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). 

CVD-04 FH Screening 

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.

CVD-04 
Previous Page Home Next Page 
Percentage of patients aged <30y with a cholesterol >7 5 OR aged with a cholesterol O who have been referred for assessment for familial hypercholesterolaemia 
Payment range 20-48% Payment size also determined by number of people with these high cholesterol readings 
Referral for assessment for familial 
hyper cholesterolaemia 
Exceptions 
2. 
3. 
4. 
Add to palliative care list 
Referral for FH assessment declined (current year) 
Secondary hyperlipdaemia (after 1st high chol) 
Genetically confirmed FH 
NB - the business rules for this indicator are very oddly constructed Patients are removed from the denominator (so PCNs penalised) if patients are diagnosed 
with FH or secondary hyperlipidaemia

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 

CVD-05 AF Treated Appropriately

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.

OCS On Drug Requiring Monitoring: Monitoring up to date 
Action More 
'IF CVD-05 Consider Anticoagulation : Consider appropriate anticoagulation for AF 
Test ACR: !!!!! PLEASE CHECK ACR 
More 
Action 
More
'IF CVD-05 Consider Anticoagulation 
Consider appropriate anticoagulation for AF

The template has links to the Atrial Fibrillation and Anticoagulation templates 

CVD-05 
Previous Page Home Next Page 
Percentage of patients on the OOF AF register and with a CHA2DS2-VASc score of (El if not female), prescribed a DOAC, or, if a DOAC is declined or unsuitable, a 
Vitamin K antagonist 
Payment range 70-95% Payment size also determined by number of people in the denominator Mod/high risk AF 
NB DOACs should not be given to patients with mechanical heart valves or antiphospholipid syndrome. 
AF Atrial Fibrillation 
Anticoagulation 
Exceptions - DOAC 
Apixaban 5mgtablets 
+ waffarin given 
+ waffarin given 
+ waffarin given 
+ waffarin given 
+ TTR + waffarin given 
QOF X 
14 Dem tae 56 
2. 
3. 
4. 
5. 
Mechanical cardiac valve prosthesis 
Antiphosp ho lipid syndrome 
DOAC contraindicated codes (ever) 
DOAC declined (current year) 
DOAC not indicated 
Exceptions - Warfarin 
War farin declined (current year) 
2. VKA contraindicated codes (ever ) 
Exceptions - General 
Declined oral anticoagulant (current year) 
2. 
3. 
Oral anticoagulant contraindication (current year) 
Oral anticoagulant contraindication (ever)

Performance and Work-to-do searches are available: 

CORC contracting (20S) 
PCN (148) 
aoF (33) 
• Time Limited Indicators (2) 
• Vaccines (8) 
4 CVD-04 FH Screening - Chol >7 5/>g at <30y/30ft - Referred for assessment - Achievement (Payment Range 20-4m 
4 CVD-04 FH Screening - Chol >7 5/>g at <30y/30ft - Referred for assessment - Work to do 
4 CVO-04 1 FH Screening - Chol >7 5/>g at <30y/30ft - Referred for assessment - Work to do - PHx referral to lipid cl 
4CVO-05-AF modJhi h risk -treateda ro riatel -Achievement Pa ment Ran e 70-95% 
4 CVD-05 - AF (modJhigh risk) - treated appropriately - Work to do 
4 CVO-06 - AF (modJhigh risk) - on Edoxaban as DOAC - Achievement (Payment Range 25-35%)
CVD-06 AF on Edoxaban as DOAC

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. 

'IF CVD-06 Consider switch to Edoxaban 
Please consider switch to Edoxaban
'IF CVD-06 Consider switch to Edoxaban: Please consider switch to Edoxaban 
1m ms - Consider Covidl g Vaccination: Consider a Covid19 vaccination 
Action 
Action 
More 
More

The template has a link to the Anticoagulation template 

CVD-06 
Previous Page Home Next Page 
Number of patients that are currently prescribed Edoxaban, as a percentage of patients on the OOF AF register with a CHA2DS2-VASc or more (El if not female) and who 
are currently prescribed a DOAC 
Payment range 25-35% Payment size also determined by number of people in the denominator Mod/high risk AF on DOAC 
There are no exceptions for this indicator 
Anticoagulation 
Rivaroxaban 15mgtabl...06Jum Tak..28t„

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

PC-01 Social Prescribing Service

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) 

PC-Ol 
Previous Page 
Home 
Page 
Percentage of registered patients referred to a social prescribing service 
Payment range 1.2-1.8% ofthe population. Payment size also determined by list size 
Referral to social prescribing service 
Social prescribing declined

A performance search is available 

CORC contracting (20S) 
PCN (148) 
aoF (33) 
• Time L mited Indicators (2) 
• Vaccines (8) 
• Weight Management (18) 
! IIF 1 4 CVO-06 - AF (modJhigh risk) - on Edoxaban as COAC- Work to do 
! IIF 2 Providing High Quality Care 
! llF21 Social Prescribin 
! IIF 2 1 PC-Ol Social Prescribing Link Worker Referral (Payment range 12-16%) 
! llF22 Enhanced Care in Care Homes 
! IIF 22 EHCH-OI - Requires accurate recording of care home status (check all residents coded) 
! IIF 22 EHCH-02 - Personal Care and Support Plan - EOY Achieved (Payment range 80-98%)

Enhanced Health in Care Home

EHCH-01 Requires Accurate Recording of Care Home Status

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. 

EHCH-02 Personal Care and Support Plan

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: 

EHCH-04 Weekly Care Home Contacts

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. 

EHCH-06 Number of Emergency Admissions 

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

AC-02 Emergency Admissions for Ambulatory Care Sensitive Conditions

Standardised number of emergency admissions for specified Ambulatory Care Sensitive Conditions per registered patient 

This indicator involves reducing the number of admissions for the following conditions. 

Conditions Amenable to Preventative Care 

  • Asthma 
  • Congestive heart failure 
  • Diabetes complications  
  • COPD 
  • Hypertension 
  • Convulsions and epilepsy acute presentation 

Conditions Amenable to Prompt Response

  • Influenza & Pneumonia  
  • Pyelonephritis 
  • Cellulitis 
  • ENT infections 

Cancer

CAN-01 LGI Referral with FIT –7d to +14d

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. 

CAN-OI 
Previous Page Home Next Page 
Percentage of LGI two week wait cancer referrals accompanied by a FIT result, result recorded in the 7 days leading up to the referral or in the 14 days after the referral 
Applies to each referral 
Payment range 40-80% Payment size also determined by number of referrals 
NB This indicator is almost impossible to achieve 
1 The FIT 'date' is the date the patient submitted the sample, not the date the result 
was received by the practice 
2 There is often a significant delay between the submitted and received dates 
2 Not all patients who need a 2ww LGI referral need a FIT test 
23 May 2022 
01 Jun 2022 
Quantitative faecal immunochemical test 24 ugJg 
Fast track referral for suspected lower Gl cancer

Access

ACC-02 Online Consultations Received

Number of online consultation submissions received by the PCN per registered patient. 

The PCN must achieved 0.26 online consultations per 1000 patients per year. Data is extracted from the online consultation provider, not from the GP system. 

SUSPENDED FOR 22/23 

ACC-05 GP Patient Survey Results

By 31 March 2023, make use of GP Patient Survey results for practices in the PCN to (i) identify patient groups experiencing inequalities in their experience of access to general practice, and (ii) develop, publish and implement a plan to improve patient experience and access for these patient  groups, taking into account demographic information including levels of deprivation. 

ACC-07 Specialist Advice Requests

Number of pre-referral Specialist Advice requests across twelve specialties identified for accelerated delivery per outpatient first attendance 

The lower and upper thresholds for payments are for 6.6-19% of first consultations to be advice and guidance. 

Specialties are: 

  • Cardiology 
  • Dermatology 
  • Endocrinology  
  • ENT 
  • Gastroenterology  
  • Gynaecology 
  • Haematology 
  • Neurology 
  • Paediatrics 
  • Respiratory 
  • Rheumatology 
  • Urology 
ACC-08 Percentage of Patients with Booking to appt time <2 weeks

Percentage of patients whose time from booking to appointment was two weeks or less 

ACC-09 Referrals to Community Pharmacist Consultation Service

Number of referrals to the Community Pharmacist Consultation Service per registered patient 

Structured Medication Reviews and Medicines Optimisation 

SMR-01A SMR For Patients on High Risk Medication

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  

IIF SMR-OIA Possible high risk medication - 
offer SMR 
consider SMR
'IF SMR-OIA Possible high risk medication - offer SMR: Consider SMR 
Action More 
IIF SMR-02D More than one antiplatelet: Consider gastroprotection 
Action More

The template will display the reason the patient is on the high risk list.   

SMR-OIA 
Previous Page Home 
Next Page 
Percentage of patients at risk of harm due to medication errors who received a Structured Medication Review 
Payment range 44-62% Payment size also determined by number of people in the denominator 
655* NSAID w/o gastroprotection in 3m before 
2 
NSAIO with earlier OGI bleed/ulcer 
3 
Antiplatelet with earlier OGI bleedJulcer 
4 
Aspirin and another antiplatelet <28d apan 
5 
Antiplatelet and anticoagulant <28d apan 
6 
NSAIO and anticoagulant <3m apan 
7 
NSAIO and heal failure 
8 NSAID and earlier eGFR<45 
Non-selective betablocker and asthma 
Medication Review Tool 
Exceptions 
Structured medication review declined 
Add to palliative care list 
Show Scripts 
Show Scripte 
Show Scripts 
Show Scripts 
NO record of structured medication review 
Aspirin and another antiplatelet within 28d of each other

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. 

Current Repeats 
Aspirin 75mg dispersible tablets 
All Scripts 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tablets 
Aspirin 75mg dispersible tablets 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tablets 
Aspirin 75mg dispersible tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tablets 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tablets 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tablets 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tablets 
Aspirin 75mg dispersible tablets 
24 May 2022 
take one d 28 tablet 
take one twice daily until 28/5/ 
take one daily 
take one daily 
take one twice daily until 28/5/ 
take one twice daily until 28/5" 
take one daily 
take one daily 
take one twice daily until 28/5/ 
take one daily 
take one twice daily until 28/5/ 
take one twice daily until 28/5" 
take one twice daily until 28/5/ 
take one daily 
take one twice daily until 28/5/ 
take one daily 
take one twice daily until 28/5/ 
take one twice daily until 28/5" 
take one daily 
take one twice daily until 28/5" 
take one twice daily until 28/5/ 
take one daily 
take one daily 
18 Jun 2021 
18 Jun 2021 
lg Jul 2021 
Iguu12021 
12 Aug 2021 
12 Aug 2021 
02 sep 2021 
02 sep 2021 
2g sep 2021 
2g sep 2021 
01 Nov 2021 
30 Nov 2021 
Jan 2022 
05 Jan 2022 
01 2022 
01 Feb2022 
04 Mar 2022 
04 Mar 2022 
31 Mar 2022 
27 Apr 2022 
27 Apr 2022 
24 May 2022

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. 

Question 
According to IIF business rules, this patient should have a structured medication review 
Do want to record an SMR? 
Go to SMR Template

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.  

Favourites (I I ) 
By Owner 
My Reports (20231 
Arfans searches (I 
CORC (3949) 
CORC contracting (20S) 
PCN (148) 
aoF (33) 
• Time Limited Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
CORC Groups (593) 
CORC Medicines (28) 
CORC Performance (223) 
CORC Population Heath (308) 
CORC aualty (8859) 
Admission (9) 
Breast (8) 
! llF25 SMR-OI Structured Medication Reviews - End of Year 
! IF 25 SMR-OI 
A- High Risk Medication with SMR - EOY Achieved (Payment Range 44-62%) 
! IF 25 SMR-OI A- High Risk Medication with SMR -EOY Work to do- Offer SMR 
IIF25SMR-01 
A- High Risk Medication with SMR - EOY Work to do - with med review in current year (SMR) 
8 - Frail patients with SMR - EOY Achieved (Payment Range 44-62%) 
F 25 SMR-OI a- Frail patients with SMR - EOY Work to do - Offer SMR 
31 - Frail patients with SMR - EOY Work to do - with med review in current year (not SMR) 
82 - Frail patients With SMR - EOY Currently excepted 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
! IF 25 SMR-OI 
C - Addictive Medicines with SMR - EOY Achieved (Payment Range 44-62%) 
C - Addictive Medicines with SMR - EOY Work to do - Offer SMR 
C - Addictive Medicines with SMR - EOY Work to do - with med review in current year (not SMR) 
O - Care Home Residents - EOY Achieved (Payment range 44-62%) 
O - Care Home Residents - EOY Work to do - Offer SMR 
O - Care Home Residents - EOY Work to do - With med review in current year (not SMR) 
El - Any Category - EOY Work to do - Offer SMR 
El 
1 - Any Category - EOY Work to do - med review in current year (not SMR) 
El 2->1 Category - EOY Work to do - Offer SMR 
E2 - Currently excepted EOY - Consider SMR 
E22 - Currently excepted EOY - med review in current year (not SMR) 
Structured Medication Reviews - How Am Driving 
Hi h Risk Medication with SMR- HAD Work to do -Offer SMR 
IF 25 SMR-018- Frail patients with SMR - HAIO Work to do -Offer SMR
SMR-01B SMR For Frail Patients

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  

•k 'IF SMR-OIB severe Frailty -offer SMR 
Consider structured medication review
'IF SMR-OI 8 Severe Frailty - offer SMR: Consider structured medication review 
Test ACR: !!!!! PLEASE CHECK ACR 
More 
Action More
SMR-OIB 
Previous Page Home Next Page 
Percentage of patients living with severe frailty who received a Structured Medication Review 
Payment range 44-62% Payment size also determined by number of people with severe frailty 
Medication Review Tool 
Exceptions 
Structured medication review declined 
Add to palliative care list 
NO record of structured medication review

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. 

Question 
According to IIF business rules, this patient should have a structured medication review 
Do want to record an SMR? 
Go to SMR Template

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. 

! IIF25SMR-01 
A- High Risk Medication with SMR - EOY Work to do - with med review in current year (SMR) 
SMR-OI 
8 - Frail patients With SMR - EOY Achieved (Payment Range 44-62%) 
IF 25 SMR-OI a- Frail patients with SMR - EOYWork to do -Offer SMR 
! IF 25 SMR-OI 
31 - Frail patients With SMR - EOY Work to do - With med review in currentyear (not SMR) 
IIF25SMR-01 
82 - Frail patients with SMR - EOY Currently excepted 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
C - Addictive Medicines with SMR - EOY Achieved (Payment Range 44-62%) 
C - Addictive Medicines with SMR - EOY Work to do - Offer SMR 
C - Addictive Medicines with SMR - EOY Work to do - With med review in current year (not SMR) 
O - Care Home Residents - EOY Achieved (Payment range 44-62%) 
O - Care Home Residents - EOY Work to do - Offer SMR 
O - Care Home Residents - EOY Work to do - With med review in current year (not SMR) 
El - Any Category - EOY Work to do - Offer SMR 
El 
1 - Any Category - EOY Work to do - med review in current year (not SMR) 
El 2->1 Category - EOY Work to do - Offer SMR 
E2 - Currently excepted EOY - Consider SMR 
E22 - Currently excepted EOY - med review in current year (not SMR) 
Structured Medication Reviews - How Am Driving 
F 25 SMR-OIA 
F 25 SMR-OIA 
! IF 25 SMR-OIA 
! SMR-018 
!IIF25SMR-018- 
!IIF25SMR-018- 
IF 25 SMR-OIC- 
- High Risk Medication with SMR - HAD Achieved (Payment Range 44-62%) 
- High Risk Medication with SMR - HAD Work to do - Offer SMR 
- High Risk Medication with SMR - HAD Work to do - with med review in current year (SMR) 
- Frail patients With SMR - HAD Achieved (Payment Range 44-62%) 
Frail patients with SMR - HAD Work to do - Offer SMR 
Frail atients with SMR- HAD Work to do-with med reviewin current ear not SMR 
Addictive Medicines with SMR - HAIO Achieved (Payment Range 44-62%)

* 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. 

SMR-01C SMR For Addictive Medicines

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  

O dl ! 
'IF SMR-OIC Addictive medicines - offer SMR 
Consider structured medication review
HIV - Consider Screening: Consider HW screen 
Action More 
'IF SMR-OIC Addictive medicines - offer SMR: Consider structured medication review 
Action More

The template will display the reason the patient is on the addictive medicines list.   

SMR-OIC 
Previous Page Home Next Page 
Percentage of patients using potentially addictive medicines who received a Structured Medication Review 
Expand this box 
Payment range 44-62% Payment size also determined by number in the denominator 
All patients 
T Benzo and gabapentinoid on the same day 
2 Benzo and gabapentinoid scripts within 3m 
Excluding patients with cancer code in L6M 
3 Benzo and strong opi0id on the same day 
4 Gabapentinoid and strong opi01d on same day 
5 benzo, gabapentinoid or strong opi01d scripts within 3m 
& Very strong opi01d 
Strong opioid: 
Virtually all opi01ds apan from codeine and dihydrocodeinæ 
V strong opi01d 
Morphine=60, oxycodone=40, fentanyl=50, buprenorphlne=525 
Medication Review Tool 
Exceptions 
Structured medication review declined 
Add to palliative care list 
For groups 3-6 only 
Add a cancer code in the last 6 months ofthe financial year 
NB for existing cancer ensure the code has ONGOING episodicity 
so it is not counted as a new cancer 
NO record of structured medication review 
Co-codamol 8mg/5„ 
ONE OR 
Co-codamol 8mg/i 
ONE OR 
Co-codamol 8mg/5 
ONE OR 
Co-codamol 8mg/i 
ONE OR 
Pregabalin 25mg one 
Pregatalin 25mg one 
Pregabalin 25mg one 
Pregabalin 25mg cantake one 
19 Apr 2021 
27 May 2021 
17 Jun 2021 
23 Aug 2021 
15 Mar 2022 
06 Apr 2022 
2g Apr 2022 
20 May 2022

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. 

Question 
According to IIF business rules, this patient should have a structured medication review 
Do want to record an SMR? 
Go to SMR Template

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.  

CORC contracting (383) 
PCN DES (IBS) 
aoF (194) 
• Time Limned Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
CORC Groups (2492) 
CORC Medicines (28) 
CORC Performance (340) 
CORC Population Heath (374) 
CORC Quality (11397) 
CORC Research (1854) 
CORC Vaccinations (1893) 
copl (2) 
cov10 (2) 
covi0 vaccine (2) 
COV1019 At Risk (503) 
COV1019 At Risk Patients v3 (330) 
COV1019 At Risk Patients v4 (2S8) 
COV1019 Vaccination (7) 
COV1019 mmunisation programme (I 
COV1019 nMAa eliaibiltv 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
SMR-OI 
! IF 25 SMR-OI 
! IF 25 SMR-OI 
! IF 25 SMR-OI 
! IIF25SMR-01 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI A- High Risk Medication with SMR - EOY Work to do - Offer SMR 
A- High Risk Medication with SMR - EOY Work to do - With med review in current year (SMR) 
8 - Frail patients with SMR - EOY Achieved (Payment Range 44-62%) 
F 25 SMR-OI a- Frail patients with SMR - EOY Work to do - Offer SMR 
31 - Frail patients with SMR - EOY Work to do - with med review in current year (not SMR) 
82 - Frail patients with SMR - EOY Currently excepted 
C - Addictive Medicines With SMR - EOY Achieved (Payment Range 44-62%) 
C - Addictive Medicines with SMR - EOY Work to do - Offer SMR 
C - Addictive Medicines With SMR - EOY Work to do - With med review in currentyear (not SMR) 
O - Care Home Residents - EOY Achieved (Payment range 44-62%) 
O - Care Home Residents - EOY Work to do - Offer SMR 
O - Care Home Residents - EOY Work to do - with med review in current year (not SMR) 
El - Any Category - EOY Work to do - Offer SMR 
El 
1 - Any Category - EOY Work to do - med review in current year (not SMR) 
El 2->1 Category - EOY Work to do - Offer SMR 
E2 - Currently excepted EOY - Consider SMR 
E22 - Currently excepted EOY - med review in current year (not SMR) 
Structured Medication Reviews - How Am Driving 
F 2 5 SMR-OIA- High Risk Medication with SMR - HAD Achieved (Payment Range 44-62%) 
F 2 5 SMR-OIA- High Risk Medication with SMR - HAD Work to do - Offer SMR 
F 2 5 SMR-OIA- High Risk Medication with SMR - HAD Work to do - With med review in current year (SMR) 
F 25 SMR-018- Frail patients with SMR - HAD Achieved (Payment Range 44-62%) 
F 25 SMR-018- Frail patients with SMR - HAD Work to do - Offer SMR 
! IIF 25 SMR-0131 - Frail patients with SMR - HAD Work to do - with med review in current year (not SMR) 
! IF 25 SMR-OIC - Addictive Medicines with SMR - 
HAD Achieved (Payment Range 44-62%) 
! IF 2 5 SMR-OIC - Addictive Medicines with SMR - HAD Work to do - Offer SMR 
IF 25 SMR-OIC - Addictive Medicines with SMR - 
HAD Workto do-with med reviewin current ear not SMR
SMR-01D SMR For Care Home Residents

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.

"F SMR-OID Care home residents - offer 
SMR 
Please consider new care home residents - offer 
SMA
'IF SMR-OIC Addictive medicines - offer SMR: Consider structured medication review 
Action More 
IIF SMR-OI D Care home residents - offer SMR: Please consider new care home residents. offer SMR 
Action
SMR-OID 
Previous Page Home Next Page 
Percentage of permanent care home residents aged 18 years or over who received a Structured Medication Review 
NO record of structured medication review 
Medication Review Tool 
Exceptions 
Structured medication review declined

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. 

Question 
According to IIF business rules, this patient should have a structured medication review 
Do want to record an SMR? 
Go to SMR Template

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.  

CORC contracting (383) 
(IBS) 
aoF (194) 
• Time Limited Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
CORC Groups (2492) 
CORC Medicines (28) 
CORC Performance (340) 
CORC Population Heath (374) 
CORC aualty (11397) 
CORC Research (1854) 
CORC Vaccinations (1893) 
• COPI (2) 
covi0 (2) 
COV10 vaccine (2) 
COV1019 At Risk (503) 
COV1019 At Risk Patients v3 (330) 
COV1019 At Risk Patients v4 (2S8) 
COV1019 Vaccination (7) 
SMR-OI 
SMR-OI 
! IIF25SMR-01 
SMR-OI 
! IF 25 SMR-OI 
! IF 25 SMR-OI 
! IF 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
F 25 SMR-OI 
C - Addictive Medicines with SMR - EOY Achieved (Payment Range 44-62%) 
C - Addictive Medicines with SMR - EOY Work to do - Offer SMR 
C- Addictive Medicines with SMR - EOY Work to do - with med review in current year (not SMR) 
D - Care Home Residents - EOY Achieved (Payment range 44-62%) 
O - Care Home Residents - EOY Work to do - Offer SMR 
D - Care Home Residents - EOY Work to do - With med review in current year (not SMR) 
El - Any Category - EOY Work to do - Offer SMR 
El 
1 - Any Category - EOY Work to do - med review in current year (not SMR) 
El 2->1 Category - EOY Work to do - Offer SMR 
E2 - Currently excepted EOY - Consider SMR 
E22 - Currently excepted EOY - med review in current year (not SMR) 
Structured Medication Reviews - How Am Driving 
F 2 5 SMR-OIA- High Risk Medication with SMR - HAD Achieved (Payment Range 44-62%) 
F 2 5 SMR-OIA- High Risk Medication with SMR - HAD Work to do - Offer SMR 
F 2 5 SMR-OIA- High Risk Medication with SMR - HAD Work to do - with med review in current year (SMR) 
F 25 SMR-018- Frail patients with SMR - HAD Achieved (Payment Range 44-62%) 
F 25 SMR-018- Frail patients with SMR - HAD Work to do - Offer SMR 
F 25 SMR-0131 - Frail patients with SMR - HAD Work to do - with med review in current year (not SMR) 
F 25 SMR-OIC 
F 25 SMR-OIC 
! IIF25SMR-01C 
! IF 25 SMR-OID 
! IIF25SMR-010- 
! IF 25 SMR-OIO- 
IF 25 SMR-OIEI - 
- Addictive Medicines with SMR - HAD Achieved (Payment Range 44-62%) 
- Addictive Medicines with SMR - HAD Work to do - Offer SMR 
- Addictive Medicines with SMR - HAD Work to do - with med review in current year (not SMR) 
- Care Home Residents - HAD Achieved (Payment range 44-62%) 
Care Home Residents - HAD Work to do - Offer SMR 
Care Home Residents - HAD Work to do - With med review in current ear not SMR 
Any Category - HAIO Work to do - Offer SMR
SMR-02A NSAID/Anticoagulant on Gastroprotection

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  

'IF SMR-02D More than one antiplatelet 
Consider gastroprotection
'IF SMR-OIA Possible high risk medication - offer SMR: Consider SMR 
Action More 
IIF SMR-02D More than one antiplatelet: Consider gastroprotection 
Action More

The template will show the relevant medications. 

SMR-02A 
Previous Page Home Next Page 
Percentage of patients 185* prescribed both an NSAID and an anticoagulant in the last 3 months ofthe previous financial year, who in the 3 months to the end ofthis year 
were either (i) no longer prescribed an NSAID or (ii) prescribed a gastroprotectwe in addition to both an NSAIO and an oral anticoagulant 
Gastroprotection 
Current Repeats 
Naproxen 500mg tablets 
Lansoprazole 15mg gastro-resistant cæ 
Apixaban 5mg tablets 
All Scripts 
Naproxen 500mg tablets 
Apixaban 5mg tablets 
Naproxen 500mg tablets 
Apixaban 5mg tablets 
Naproxen 500mg tablets 
Apixaban 5mg tablets 
Expand this box 
08 Jun 2022 MICE 
56 tablet 
May2022 take omm28 cap 
12 May2022 Take on 
56 tablet 
Lansoprazole 15mg gastro-resistant cap. nake one once daily 
Naproxen 500mg tablets 
Apixaban 5mg tablets 
Lansoprazole 15mg gastro-resistant caps 
Naproxen 500mg tablets 
Apixaban 5mg tablets 
Lansoprazole 15mg gastro-resistant cap. nake one once daily 
Naproxen 500mg tablets 
Apixaban 5mg tablets 
Lansoprazole 15mg gastro-resistant caps 
Naproxen 500mg tablets 
Apixaban 5mg tablets 
Lansoprazole 15mg gastro-resistant cap. nake one once daily 
Naproxen 500mg tablets 
MICE A DAY AFTE 
Take one twice daily 
TWICE A DAY AFTE 
Take one twice daily 
A DAY AFTE 
Take one twice daily 
MICE A DAY AFTE 
Take one twice daily 
nake one once daily 
TWICE A DAY AFTE 
Take one twice daily 
MICE A DAY AFTE 
Take one twice daily 
nake one once daily 
A DAY AFTE 
Take one twice daily 
MICE A DAY AFTE 
30 Mar 2021 
27 Apr 2021 
27 Apr 2021 
25 May 2021 
25 May 2021 
23 Jun 2021 
23 Jun 2021 
23 Jun 2021 
22 Jul 2021 
22 Jul 2021 
22 Jul 2021 
17 Aug2021 
17 Aug 2021 
17 Aug 2021 
15 sep 2021 
15 sep 2021 
15 sep 2021 
12 Oct 2021 
12 Oct 2021 
12 Oct 2021

Performance and Work-to-do searches are available.  The EOY searches will only be useful in the final three months of the financial year. 

Automatic immunisation messaging (I 
CORC (S882) 
CORC contracting (383) 
(IBS) 
aoF (194) 
• Time Limned Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
a 
CORC Groups (2492) 
CORC Medicines (28) 
CORC Performance (340) 
CORC Population Heath (374) 
CORC Quality (11397) 
CORC Research (1854) 
CORC Vaccinations (1893) 
COPI (2) 
covi0 (2) 
covi0 vaccine (2) 
COV1019 At Risk (503) 
COV1019 At Risk Patients v3 (330) 
COV1019 At Risk Patients v4 (2S8) 
COV1019 Vaccination (7 
F 25SMR-01E1 
1 - Any Category - HAD Work to do - With med review in current year (not SMR) 
F 25 SMR-OIEI 2--1 category - HAD Work to do - Offer SMR 
F 25SMR-01E2- 
Currently excepted HAD - Consider SMR 
SMR-01E2- 
Currently excepted HAD - Consider SMR - With med review in current year (not SMR) 
!IIF25SMR-02 Gastro rotection 
! IIF 25 SMR-02 Gastroprotection End of Year Searches 
! llF25SMR-02 Gastroprotection Nathe EOY searches Will be accurate in the last 3 months ofthe financial year 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Work to do 
IF 25 SMR-02 Total A-O - Gastroprotection - EOY Work to do 
! IIF 25 SMR-02 Gastroprotection How AM Driving Searches 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Work to do 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Work to do 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 75-90%) 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Work to do 
IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Achieved (Payment Range 75-90%) 
25 SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Work to do 
! IF 25 SMR-02TotaI A-D - Gastroprotecton - HAD Work to do 
! IF SMR-03 oogcoosina

Tip For Achieving This Indicator 

Use the HAID reports until the last 3 months of the financial year. 

SMR-02B NSAID Not Anticoagulant on Gastroprotection 

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  

'IF SMR-02D More than one antiplatelet 
Consider gastroprotection
'IF SMR-OIA Possible high risk medication - offer SMR: Consider SMR 
Action More 
IIF SMR-02D More than one antiplatelet: Consider gastroprotection 
Action More

The template will show the relevant medications. 

SMR-02B 
Previous Page Home Next Page 
Percentage of patients 655* prescribed an NSAID (but not an oral anticoagulant) in the last 3 months of the previous financial year, who in the last 3 months ofthe current 
year were either (i) no longer prescribed an NSAID or (ii) prescribed a gastroprotectwe in addition to an NSAID 
Expand this box 
Lansoprazole 15mg take one once 24 Feb 2022 
Current Repeats 
Gastroprotection 
All Scripts 
Naproxen 500mg tablets 
ONE TO BE 24 Feb 2022

Performance and Work-to-do searches are available.  The EOY searches will only be useful in the final three months of the financial year. 

Automatic immunisation messaging (I 
CORC (S882) 
CORC contracting (383) 
(IBS) 
aoF (194) 
• Time Limned Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
a 
CORC Groups (2492) 
CORC Medicines (28) 
CORC Performance (340) 
CORC Population Heath (374) 
CORC Quality (11397) 
CORC Research (1854) 
CORC Vaccinations (1893) 
COPI (2) 
covi0 (2) 
covi0 vaccine (2) 
COV1019 At Risk (503) 
COV1019 At Risk Patients v3 (330) 
COV1019 At Risk Patients v4 (2S8) 
COV1019 Vaccination (7 
F 25SMR-01E1 
1 - Any Category - HAD Work to do - With med review in current year (not SMR) 
F 25 SMR-OIEI 2--1 category - HAD Work to do - Offer SMR 
F 25SMR-01E2- 
Currently excepted HAD - Consider SMR 
SMR-01E2- 
Currently excepted HAD - Consider SMR - With med review in current year (not SMR) 
!IIF25SMR-02 Gastro rotection 
! IIF 25 SMR-02 Gastroprotection End of Year Searches 
! llF25SMR-02 Gastroprotection Nathe EOY searches Will be accurate in the last 3 months ofthe financial year 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Work to do 
IF 25 SMR-02 Total A-O - Gastroprotection - EOY Work to do 
! IIF 25 SMR-02 Gastroprotection How AM Driving Searches 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Work to do 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Work to do 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 75-90%) 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Work to do 
IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Achieved (Payment Range 75-90%) 
25 SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Work to do 
! IF 25 SMR-02TotaI A-D - Gastroprotecton - HAD Work to do 
! IF SMR-03 oogcoosina

Tip For Achieving This Indicator 

Use the HAID reports until the last 3 months of the financial year. 

SMR-02C Antiplatelet/Anticoagulant on Gastroprotection

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  

'IF SMR-02D More than one antiplatelet 
Consider gastroprotection
'IF SMR-OIA Possible high risk medication - offer SMR: Consider SMR 
Action More 
IIF SMR-02D More than one antiplatelet: Consider gastroprotection 
Action More

The template will show the relevant medications. 

SMR-02C 
Previous Paca Home Next Page 
Percentage of patients 185* prescribed both an oral anticoagulant and an anti-platelet in the last 3 months ofthe previous financial year, who in last 3 months ofthe current 
year were either (i) no longer prescribed an anti-platelet or (ii) prescribed a gastroprotectwe in addition to both an oral anticoagulant and an anti-platelet 
Expand this box 
Gastroprotection 
Current Repeats 
Lansoprazole 15mg gastro-res 
15 Jun 2 take 
Apixaban 5mg tablets 
15 Jun 2m Take 
All Scripts 
Lansoprazole 15mg take one once 
Aspirin 75mg dispersible tablets 
take one daily 
Aspirin 75mg dispersible tablets 
take one daily 
Lansoprazole 15mg take one once 
Aspirin 75mg dispersible tablets 
take one daily 
Lansoprazole 15mg take one once 
Aspirin 75mg dispersible tablets 
take one daily 
Lansoprazole 15mg take one once 
Aspirin 75mg dispersible tablets 
take one daily 
Lansoprazole 15mg take one once 
Lansoprazole 15mg take one once 
Aspirin 75mg dispersible tablets 
take one daily 
Aspirin 75mg dispersible tablets 
take one daily 
Lansoprazole 15mg take one once 
Aspirin 75mg dispersible tablets 
take one daily 
Lansoprazole 15mg take one once 
Aspirin 75mg dispersible tablets 
take one daily 
Lansoprazole 15mg take one once 
Apixaban 5mg tablets 
Take one twice„ 
Lansoprazole 15mg take one once 
Apixaban 5mg tablets 
Take one twice„ 
Apixaban 5mg tablets 
Take one twice 
Lansoprazole 15mg take one once 
28 cc 
22 Jun 2021 
25 Jun 2021 
08 Jul 2021 
08 Jul 2021 
13 Aug 2021 
25 Aug 2021 
07 sep 2021 
16 sep 2021 
06 Oct 2021 
06 Oct 2021 
03 Nov2021 
08 Nov 2021 
24 Nov2021 
24 Nov 2021 
13 Dec 2021 
13 Dec 2021 
12 Jan 2022 
12 Jan 2022 
31 Jan 2022 
21 Feb 2022 
21 Feb2022 
15 Mar 2022 
15 Mar 2022 
2 
2

Performance and Work-to-do searches are available.  The EOY searches will only be useful in the final three months of the financial year. 

Automatic immunisation messaging (I 
CORC (S882) 
CORC contracting (383) 
(IBS) 
aoF (194) 
• Time Limned Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
a 
CORC Groups (2492) 
CORC Medicines (28) 
CORC Performance (340) 
CORC Population Heath (374) 
CORC Quality (11397) 
CORC Research (1854) 
CORC Vaccinations (1893) 
COPI (2) 
covi0 (2) 
covi0 vaccine (2) 
COV1019 At Risk (503) 
COV1019 At Risk Patients v3 (330) 
COV1019 At Risk Patients v4 (2S8) 
COV1019 Vaccination (7 
F 25SMR-01E1 
1 - Any Category - HAD Work to do - With med review in current year (not SMR) 
F 25 SMR-OIEI 2--1 category - HAD Work to do - Offer SMR 
F 25SMR-01E2- 
Currently excepted HAD - Consider SMR 
SMR-01E2- 
Currently excepted HAD - Consider SMR - With med review in current year (not SMR) 
!IIF25SMR-02 Gastro rotection 
! IIF 25 SMR-02 Gastroprotection End of Year Searches 
! llF25SMR-02 Gastroprotection Nathe EOY searches Will be accurate in the last 3 months ofthe financial year 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Work to do 
IF 25 SMR-02 Total A-O - Gastroprotection - EOY Work to do 
! IIF 25 SMR-02 Gastroprotection How AM Driving Searches 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Work to do 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Work to do 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 75-90%) 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Work to do 
IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Achieved (Payment Range 75-90%) 
25 SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Work to do 
! IF 25 SMR-02TotaI A-D - Gastroprotecton - HAD Work to do 
! IF SMR-03 oogcoosina

Tip For Achieving This Indicator 

Use the HAID reports until the last 3 months of the financial year. 

SMR-02D Aspirin/Antiplatelet on Gastroprotection

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  

'IF SMR-02D More than one antiplatelet 
Consider gastroprotection
'IF SMR-OIA Possible high risk medication - offer SMR: Consider SMR 
Action More 
IIF SMR-02D More than one antiplatelet: Consider gastroprotection 
Action More

The template will show the relevant medications. 

SMR-02D 
Previous Page Home Next Page 
Percentage of patients aged 18 years or over prescribed aspirin and another anti platelet in the last three months ofthe previous financial year, who in the three months to th 
reporting period end date were either (i) no longer prescribed aspirin and/or no longer prescribed an anti-platelet or (ii) prescribed a gastroprotectwe in addition to both 
aspirin and another anti-platelet 
Gastroprotection 
Expand this box 
Current Repeats 
Aspirin 75mg dispersible tablets24 May 2m take 28 tan 
All Scripts 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tabl„ 
Aspirin 75mg dispersible tabl 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tabl 
Aspirin 75mg dispersible tatl„ 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tatl„ 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tabl 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tatl„ 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tabl„ 
Ticagrelor gomg tablets 
Ticagrelor gomg tablets 
Aspirin 75mg dispersible tatl„ 
Aspirin 75mg dispersible tabl„ 
take one twice„ 
take one daily 
take one daily 
take one twice„ 
take one twice 
take one daily 
take one daily 
take one twice„ 
take one daily 
take one twice„ 
take one twice„ 
take one twice„ 
take one daily 
take one twice„ 
take one daily 
take one twice„ 
take one twice 
take one daily 
take one twice„ 
take one twice„ 
take one daily 
take one daily 
18 Jun 2021 
18 Jun 2021 
lg Jul 2021 
Iguu12021 
12 Aug 2021 
12 Aug 2021 
02 sep 2021 
02 2021 
2g sep 2021 
2g sep 2021 
01 Nov 2021 
30 2021 
05 Jan 2022 
05 Jan 2022 
01 2022 
01 Feb2022 
04 Mar 2022 
04 Mar 2022 
31 Mar 2022 
27 Apr 2022 
27 Apr 2022 
24 May 2022

Performance and Work-to-do searches are available.  The EOY searches will only be useful in the final three months of the financial year. 

Automatic immunisation messaging (I 
CORC (S882) 
CORC contracting (383) 
(IBS) 
aoF (194) 
• Time Limned Indicators (2) 
• Vaccines (8) 
Weight Management (18) 
a 
CORC Groups (2492) 
CORC Medicines (28) 
CORC Performance (340) 
CORC Population Heath (374) 
CORC Quality (11397) 
CORC Research (1854) 
CORC Vaccinations (1893) 
COPI (2) 
covi0 (2) 
covi0 vaccine (2) 
COV1019 At Risk (503) 
COV1019 At Risk Patients v3 (330) 
COV1019 At Risk Patients v4 (2S8) 
COV1019 Vaccination (7 
F 25SMR-01E1 
1 - Any Category - HAD Work to do - With med review in current year (not SMR) 
F 25 SMR-OIEI 2--1 category - HAD Work to do - Offer SMR 
F 25SMR-01E2- 
Currently excepted HAD - Consider SMR 
SMR-01E2- 
Currently excepted HAD - Consider SMR - With med review in current year (not SMR) 
!IIF25SMR-02 Gastro rotection 
! IIF 25 SMR-02 Gastroprotection End of Year Searches 
! llF25SMR-02 Gastroprotection Nathe EOY searches Will be accurate in the last 3 months ofthe financial year 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 85-90%) 
!IIF25SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - EOY Work to do 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Achieved (Payment Range 75-90%) 
!IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - EOY Work to do 
IF 25 SMR-02 Total A-O - Gastroprotection - EOY Work to do 
! IIF 25 SMR-02 Gastroprotection How AM Driving Searches 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
! IIF25SMR-02A 
- NSAlO/Anticoagulant on Gastroprotection - HAD Work to do 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 85-90%) 
25 SMR-028- 
65+ NSAIO not Anticoagulant on Gastroprotection - HAD Work to do 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Achieved (Payment Range 75-90%) 
! IIF25SMR-02C 
- Antiplatelet/Anticoagulant on Gastroprotection - HAD Work to do 
IIF25SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Achieved (Payment Range 75-90%) 
25 SMR-020- 
Aspirin/Antiplatelet on gastroprotection - HAD Work to do 
! IF 25 SMR-02TotaI A-D - Gastroprotecton - HAD Work to do 
! IF SMR-03 oogcoosina

Tip For Achieving This Indicator 

Use the HAID reports until the last 3 months of the financial year. 

SMR-03 DOAC Record CG Cr Cl

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 

Rivaroxaban Details poor INR Control Exceptions Resources 
Rivaroxaban Details 
BNF - Rivaroxaban 
Prevention of stroke and systemic embolism in adult patients with 
non-valvular atrial fibrillation (NVAF), with one or more risk factors, 
such as 
• prior stroke, TIA 
• congestive heal failure 
• age 75years 
• hypertension 
• diabetes mellitus 
Avoid if < 5 (USE COCKROFT GAULT) 
Take with food 
Non-valvular AF 
EHRA NOAC Guide 
Weight 
Serum creatinine level 
92.534Kg(14st81b) 31 May2022 
88 umol/L 
31 May2022 
01 Mar 2022 Estimated creatinine clearance (Cockcrott-Gault formula) 40 ml_/min 
nitially 
aintenance 
15-4g 
15mg Od for 21 d 
20mg 
onsider 15mg 
20mg od 
15mg od 
* Reduce to 10mg after 6m unless high risk of recurrence 
GFR calculated abbreviated MORO 
H/O NON-HAEMORRHAGIC STROKE OR TIA 
Heart failure and LVSD 
Has HYPERTENSION 
No record of diabetes 
! CKD ! Higher risk Of Bleeding 
Rivaroxaban Safety 
52 mumin/1 73m*2 31 May 2022 
08 Mar 2019 10:39 
ntraindicated Drugs/Drugs to 
ronedarone 
ifampicin 
IV Medication 
eto-/ltra-/Posa-Noriconazole 
iraterone/Enzalutamide 
henyloin/phenobarb 
arbamazepine 
alproic acid 
acrolimus - seek atvice 
John's Won 
tion 
iodaroneNerapamil 
uinidine 
larithromycin/Erythromycin 
luconazole 
aproxen 
RI/SNRI 
icalutamide 
astrozolenamoxifen 
iclosporin/Sirolimus 
exametasone 
evetiracetamnopiramate 
carbazepine 
Entered by 
Finished by 
LEVICK, Susan (Dr) (General Medical Practitioner) 
LEVICK, Susan (Dr) (General Medical Practitioner) 108 Mar 2019 10:39) 
Rivaroxaban Safety 
Risk of bleeding discussed 
Need to take With food discussed 
Need to monitor kidney Fx 
discussed 
Yes 
Yes 
Yes 
St John's Wort interaction discussedYes 
Anticoagulation card issued 
Yes

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. 

Question 
Has renal function result to review 
Recording Cockroft Gault Cr Cl is recommended 
decord CG cr

Respiratory Care

RESP-01 Asthma with 3 ICS in last year

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 

  1. Review the unachieved patients with asthma and COPD. 
    1. For patients on COPD ICS inhalers such as trelegy – hopefully this will be fixed in the business rules before the end of the year 
    2. For patients not on ICS inhalers, consider whether the asthma diagnosis is still relevant: 
      1. If the patient never had asthma – mark the asthma diagnosis ‘in error’ 
      2. If the patient no longer has asthma (i.e. not asthma/COPD overlap) code asthma resolved at the appropriate time. 
  2. 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 Asthma with >=6 SABA in last year

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 

  1. 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

ES-01 Non-Salbutamol MDI Prescriptions

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 

  1. Identify patients to consider for switching during LTC reviews 
  2. Identify patients to switch using the searches – consider approaching them directly. 
  3. 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 
ES-02 CO2e per Salbutamol Inhaler

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:

Salbutamol Mean CO2 CalculatorDownload

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. 

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! llF26 Respiratory 
! IF 26 RESP-OI Asthma With 3 ICS in L12M - 
EOY Achieved (F 
IF 26 RESP-OI Asthma with 3 ICS in L12M 
- EOY Work to do 
IF 26 RESP-OI Asthma with 3 ICS in L12M 
- HAD Achieved( 
IF 26 RESP-OI Asthma with 3 ICS in L12M - HAD Work to do 
IF 2 6 RESP-02 Asthma with SABA in last year - EOY Pay 
IF 2 6 RESP-02 Asthma with SABA in last year -HAID Pa: 
IF 26 RESP-TotaI 80th 01 and02 HAD Work to do 
IF 4 Sustainable NHS 
! IF 41 
! IF 41 
! IF 41 
! IF 41 
! IF 41 
! IF 41 
! IF 41 
ES-OI 
ES-OI 
ES-OI 
ES-OI 
ES-OI 
ES-OI 
ES-OI 
! IIF42ES-02 
IIF Units usin 
- Inhalers - Tl Non salb MOIS - breakdown to gE 
- Inhalers - 1 2 Non salb All - breakdown to get it 
- Inhalers - 1 3 Performance EOY is Item counts 
- Inhalers -21 Non salb MOIS - breakdown to gE 
- Inhalers -22 Non salb All - breakdown to get it 
- Inhalers -23 Performance HAD is Item counts 
- Inhalers - Consider switch from MDI to DPI - 
- Inhalers - Salbutamol - Issued in period- calcu 
alerts
  • Protocol which runs when renal function results are filed to prompt recording of CG CrCl. 

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