Graphnet Increased QOF Reviews Completed from 33% to 70% for Kumar Medical Centre

At a Glance

• Client: Kumar Medical Centre, Slough
• Technology: Graphnet Shared Care Record and the Johns Hopkins ACG® System
• Location: Slough, England
• Key result: 70% of Quality and Outcomes Framework reviews completed by September, compared with 33% in previous years. This rose to 90% by November the same year.

Discover how Kumar Medical Centre (KMC) in Slough increased the proportion of Quality and Outcomes Framework (QOF) reviews completed by September from 33% in previous years to 70%, rising to over 90% by November 2023.

Working with Frimley Integrated Care System (ICS), the practice used Graphnet’s  population health management tools and the Johns Hopkins ACG® System to segment patients by clinical complexity.

This enabled the team to prioritise patients with more complex needs, match them with the right healthcare professional and plan appointments more effectively.

By organising reviews around patient need rather than birth month, KMC improved the use of clinical resources, completed more reviews ahead of winter and created more capacity to care for other patients.

The Challenge

Kumar Medical Centre’s traditional approach to QOF reviews involved inviting patients according to their birth month and distributing appointments across qualified staff.

Every patient followed the same process, regardless of whether they were complex and multimorbid patients or relatively fit with just one of the QOF conditions.

This made it harder to deliver effective support to patients. Some patients needed repeat appointments because the healthcare professional they initially saw could not make the necessary changes to their medication.

Meanwhile, patients at greater risk of complications were not necessarily reviewed early enough to optimise their health before the winter months.

Led by Dr Priya Kumar, the practice recognised an opportunity to redesign their process and better support patients by planning QOF appointments for more complex patients earlier in the year, while resources were more flexible, and before seasonal pressures kicked in.

She explains:

“By using a population health approach and identifying our most complex patients using the Johns Hopkins Patient Need Groups, we are able to review the patients according to complexity rather than date of birth and allocate the right health care professional the first time.”

This was particularly important for complex patients, who account for approximately 60% of bed days at the local hospital.

The Solution

The Johns Hopkins ACG System uses patients’ diagnoses, conditions and medication to categorise their overall level of complexity.

Patient Need Groups (PNGs) categorise patients into one of 11 clinically relevant groups, based on their overall level of complexity. The segmentation considers a person's diagnoses, conditions and medication to identify their healthcare needs, from lower-complexity patients to those with multiple conditions, significant chronic illness or frailty.

Using Graphnet’s population health management tool in tandem with this, Kumar Medical Centre segmented all their patients requiring a QOF review into one of the 11 PNGs.

With this information, the practice redesigned its approach around patient need, considering:

• Timing: Prioritising patients with greater complexity earlier in the year, before autumn and winter pressures
• Clinical expertise: Matching patients with the most appropriate healthcare professional for their overall needs
• Appointment length: Allowing sufficient time to complete reviews effectively and reduce repeat visits
• Appointment format: Using digital reviews where appropriate, alongside face-to-face appointments

Dr Kumar explained:

“With a complex patient with diabetes or hypertension (PNG 9 and above) who is likely to have their medication reviewed – there is no point sending them first to a health care assistant to do the monitoring and then to the GP. 

We would simply allocate them to be seen by the senior diabetic nurse specialist in the first instance, who is trained to change the medication with the oversight of the GP. This approach creates vital GP capacity within the system to support other patients.”

The practice also divided face-to-face appointments for lower-need, high-volume PNG 3 patients into smaller monthly groups. This helped distribute the workload throughout the year, while allowing the team to prioritise patients with more complex needs.

The result was a more flexible, clinically informed approach to QOF reviews, with appointments organised around what patients needed rather than an administrative schedule.

The Results

The redesigned process enabled Kumar Medical Centre to complete more QOF reviews earlier in the year, helping the practice prepare patients for winter and use its clinical workforce more efficiently.

Key benefits included:

• 70% of QOF reviews completed by September: Compared with 33% in previous years. This rose to 90% by November the same year.
• Fewer repeat appointments: Matching patients with the right healthcare professional at the first appointment reduced the need for additional visits.
• More efficient use of clinical capacity: Better appointment planning helped free up GP time and make more effective use of nursing staff and other clinicians.
• Improved patient experience: Longer, appropriately allocated appointments reduced unnecessary visits, while digital reviews allowed some patients to complete checks remotely.
• Earlier care for higher-risk patients: Reviewing the most complex patients before autumn and winter gave the practice more time to optimise their health and manage seasonal pressures.
• Reduced urgent care activity: There has been a reduction of 2.8% in urgent care activity for patients at Kumar Medical Centre (4.5% against the upward trend across Slough).
• Fewer emergency care episodes: There has been a reduction in Emergency Department attendances, admissions and length of stay in Kumar Medical Centre’s population between the end of August and the end of December 2023. Again, this is against an upward trend across the rest of Slough.

The earlier completion of reviews also gave the team more time in autumn to undertake vaccinations and greater capacity during winter to see other patients promptly.

Kumar Medical Centre’s Population Health Needs Compared with the CCG Average

“After starting the process in 2023, we reviewed all the most complex patients by September… In fact, overall, we had carried out 70% of QOF reviews by September this year, as opposed to only 33% in the years before, allowing more time in the autumn to undertake vaccinations and more time in the winter months to see other patients more quickly. 

As of November 2023, this figure had risen to over 90%. By using a single metric, we seem to have solved the perennial problem of not having enough appointments. 

Using PNGs, you can organise your resources to work much more efficiently for yourself, while also bringing benefits to the wider system. Patients are seen at the right time by the right health care professional for the right amount of time. The principle is fundamentally simple, but really effective.”

How QOF Review Appointments Are Now Scheduled at Kumar Medical Centre

*Bitesize refers to the high-volume PNG 3 patients split into smaller monthly groups. Most require cervical smears, an activity that does not impact on winter pressures.

Looking to the Future

The informatics team at Frimley ICS will continue working with Dr Kumar and her colleagues to assess outcomes for patients with QOF conditions, particularly those with the most complex needs.

The evaluation will examine whether the new approach helps reduce emergency admissions and lengths of stay, building on the early reductions in urgent care activity and emergency care use observed in 2023.

There is also potential for other GP practices across the ICS to adopt the approach, using Patient Need Groups to organise resources more effectively and ensure patients receive the right care at the right time.

Turn Population Health Insights into Action

Discover how Graphnet’s population health management capabilities can help healthcare organisations use patient data to prioritise care, make better use of clinical resources and improve outcomes.

Contact Graphnet to discuss your requirements.