QOF Accident and Emergency Indicators QP12QP14
The QOF quality and productivity (QP) accident and emergency (A&E) indicators have been
introduced for one year from April 2012 and are aimed at reducing avoidable A&E
attendances. These indicators replace the 2011/12 QP indicators on prescribing (QP1, QP2,
QP3, QP4 and QP5).
To ensure prescribing improvements continue, NHS Employers and GPC negotiators have
agreed the following:
“Although the prescribing element of the quality and productivity scheme will be replaced
with A&E attendances in 2012/13, we agree that all practices in the UK should continue to
ensure cost effective prescribing when compared to peers, building on the progress
achieved in 2011/12. Those practices who remain significant outliers would also be expected
to continue to participate in external peer review during 2012/13.”
As with the outpatient referrals (QP6 and QP7) and emergency admissions (QP9 and QP10)
indicators, the A&E attendances indicators (QP12 and QP13) require that a practice
undertake an internal review followed by an external peer review.
Internal review (QP12)
PCOs are required to supply practices with data from the final quarter of the 2011/12 year (1
January to 31 March 2012) on A&E attendances which the practices reasonably require to
conduct the review. The data should, where possible, include patient details, reasons for
attendance/diagnosis and the time/date of the attendance. In order to assist PCOs in
supplying the relevant information to a practice it may be helpful for the practice and PCO to
initially discuss what data is available and how the PCO will supply the relevant information.
In doing this both the practice and PCO will be clear about the expectations regarding the
level of data available and when it will be supplied.
Scotland
A high level dataset showing numbers of all A&E attendances that are “new” or
“unplanned returns”, with age bands of 0-4, 5-15, 16-64 and over 65 and deprivation
category will be provided to practices showing comparison with other practices in the
NHS Board or CHP area and a national comparator. This dataset will not provide patient
level data or A&E diagnosis.
If for whatever reason a PCO is unable to provide the data within a reasonable timeframe
that allows practices to meet the indicator deadlines, then it is expected that the PCO will
allow practices a longer timeline to complete the review. In such circumstances a decision to
allow a longer timeline should be determined locally and clearly agreed between the PCO
and practices. Practices may wish to reference this in their reports to the PCO for each of
the indicators. Any disputes that may arise as a result of this should be handled through the
normal dispute resolution procedures.
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Scotland
In Scotland, if data is not available to allow for the internal review to take place by 30 June
2012, then practices will have eight weeks within receipt of the data in which to hold the
internal review.
The definition of ‘avoidable attendances’ should be defined by the practice and agreed with
the PCO prior to reviewing the data.
Attendances at A&E are defined as those patients seen in a Type 1 A&E department for both
first and follow-up attendances for the same condition. Attendances should not include those
that are planned or planned follow ups. For example:

where a patient has had a prior consultation with their GP for a condition that clearly
requires A&E attendance and the GP informs A&E of the impending attendance (e.g.
access to specialist/urgent diagnostics/assessment such as an x-ray for suspected
fractures and/or admission)
Scotland
The dataset described above will include all GP referrals – when doing the focused work
described below the practice will have the option to exclude these patients.

where the A&E has booked a follow up appointment.
Scotland
The dataset described above will not include these patients.

if a patient attends the department due to it being where their registered practice is
seeing their patients.
Scotland
This scenario does not apply in Scotland.
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
if it is the agreed place for a patient to be seen prior to admission.
Scotland
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The definition in the document A&E Clinical Quality Indicators Data Definitions published by
the Department of Health in England defines a Type 1 A&E department as “a consultant led
24 hour service with full resuscitation facilities and designated accommodation for the
reception of accident and emergency patients”.
In circumstances where there is no Type 1 A&E department or where the majority of patients
do not use a Type 1 A&E department, then practices and PCOs should agree the most
frequently used local urgent care service and agree those that will be included (for example
Type 2 and/or Type 3 A&E departments). The type of A&E attendance will be limited to both
first and follow-up attendances for the same condition (excluding planned follow-ups).
Scotland
In Scotland - the principle of focusing on Type 1 A and E where appropriate and thereafter
on the most frequently used local urgent care service should be applied .
For Rural Health Boards where the National QOF QP Framework may not easily apply, local
flexibility should apply and where appropriate should be agreed between the Health Board
and the LMC. Where agreement between the Health Board and the LMC is not reached, for
whatever reason, then the Scottish Government Health Department and Scottish GPC will
decide jointly. The Scottish Government will support individual boards to identify areas of
action where there are no A&E attendances.
Further information:
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digital
asset/dh_122892.pdf
The internal review should take place at least once prior to 31 July 2012, or an agreed later
date if the data is not made available, with the range of clinicians working in the practice. At
the meeting the practice will explore the reasons for registered patients’ attendance(s) at
A&E, identifying any emerging patterns and discussing this with reference to available care
pathways and the capability and access within primary care services to see and treat
patients.
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In the discussion, focus should be given to:
1. Older patients with co-morbidities at high risk of admission (patients aged 65 years and
over).
Scotland
As a subset of the main dataset described above, the practice will be provided with
patient specific data of all their patients with a SPARRA risk of >50 and an A&E
attendance in last year.
2. Children with minor illness/injury (patients aged 15 years and under).
Scotland
As a subset of the main dataset described above, practices will be provided with patient
specific data on all attendances under 16 with age categories 0-4 and 5-16 and time of
attendance. The actual A&E diagnosis will not be available within this dataset.
3. Patients who frequently re-attend A&E that could be dealt with in primary care.
Scotland
Practices will be provided with data regarding all their frequent attenders using the
nationally agreed definition of >ten attendances per year or >5 attendances in three
months.
The review should also specifically consider whether same day access to clinicians in the
practice is appropriate and whether any comparisons can be drawn between this and the
level of A&E attendances.
The output of the review must be made available to the group of practices taking part in the
external peer review meeting (QP13).
Practices are required to produce and submit a report to the PCO no later than 31 July 2012.
It is advised that the report should include the following information:

date of meeting and people in attendance

a summary of the discussions that took place at the meeting

information on what, if any, comparisons have been drawn between same day access to
clinicians in the practice and the level of A&E attendances
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
information on the practice’s current access arrangements

how the practice defined ‘avoidable attendances’.
Practices may wish to include information for discussion at the external peer review meeting
on where improvements may be made to improve the quality of care for patients at the
interface of primary care and A&E, in order to help reduce avoidable A&E attendances.
In developing the final report, practices may find it useful to refer to the Primary Care
Foundation Report Urgent Care - A Practical Guide to Reforming Same Day Care in General
Practice published in 2009. The report is available at:
www.primarycarefoundation.co.uk/files/PrimaryCareFoundation/Downloading_Reports/Repo
rts_and_Articles/Urgent_Care_Centres/Urgent_Care_May_09.pdf
External peer review (QP13)
The external peer review group must consist of a minimum of six practices. A group may
only be made up of less than six practices if agreed with the PCO, taking into account local
geography and historical groups of practices. Where possible the practices should have
similar care pathways and/or geographical locations. The group may be the same as that
used for the other QP indicators.
At the meeting each practice should be represented by at least one GP. During the external
peer review practices should compare their practice data with comparable data from
practices in the group, or all practices in the PCO area, to determine why there are any
variances and where it may be appropriate to amend current arrangements to help reduce
avoidable A&E attendances. The focus of the review will be to reflect on the reasons and/or
patterns of A&E attendances and identify where improvements may be made to improve the
quality of care for patients at the interface of primary care and A&E, in order to help reduce
avoidable A&E attendances. Focus should be given to:
1. Older patients with co-morbidities at high risk of admission (patients aged 65 years and
over).
2. Children with minor illness/injury (patients aged 15 years and under).
3. Patients who frequently re-attend A&E that could be dealt with in primary care.
Practices may also propose, via the peer group, areas for commissioning or service design
improvements to the PCOs that could help reduce avoidable A&E attendances.
Following the review, the practice improvement plan is either amended or agreed by the
group.
Practices are required to produce and submit a report to the PCO by no later than 30
September 2012. The report should include the following information:

date of meeting and details of practices in attendance

a summary of the discussions that took place at the meeting

details of the agreed improvement plan that aims reduce avoidable A&E attendances.
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Scotland
The Improvement Plan should include the following actions
1. Older patients with co-morbidities at high risk of admission (patients aged 65 years and
over) - care plan for high risk SPARRA patients (2/5000 registered list size) or all
whichever is the lesser number)to support avoidance of unnecessary A&E attendance.
The care plan is expected to follow the same process as other areas of anticipatory care
planning – Anticipatory Care Plans Frequently Asked Questions
www.scotland.gov.uk/Resource/Doc/309277/0097422.pdf
2. Children with minor illness/injury (patients aged 15 years and under) - plan to reduce
avoidable A and E attendances by this group.
3. Patients who frequently re-attend A&E that could be dealt with in primary care – care
plan for frequent attenders (2/5000 registered list size frequent attenders or all whichever
is the lesser number) to support avoidance of unnecessary A&E attendance.
An outline of key points to consider in a care plan for Frequent attenders is attached at
appendix A
4. If the practice has no or only 1 patient in either group 1 or 3, all patients in the
remaining group should be considered to allow a total of 4/5000 cases managed eg 1 in
group 1 and 3 in group 3 or vice versa, or all 4 from group 1 or group 3. If the total in both
groups is less than 4, all patients should be case managed.
5. If the practice has no patients in either group they should request and review the data
for men of working age and produce a plan to reduce any avoidable attendances.
Scotland
For Scottish practices the practice groupings will be agreed between the Health Board and
the Local Medical Committee (LMC). The report must be submitted to the Health Board by
no later than 15 March 2013.
Implementation of improvement plan (QP14)
Practices will be required to implement the arrangements and actions set out in their
improvement plans agreed in QP13. In doing this practices will need to review their monthly
data to provide information on how improvements in care and primary care access have
been made. The report should include information about (1) older patients with comorbidities at high risk of admission, (2) children with minor illness/injury and (3) patients
who frequently re-attend A&E, as well as how any improvements in care and access in
primary care have helped to reduce avoidable A&E attendances. If the data quality provided
to the practice does not allow this to be done for all patients, this should be noted in the
report.
Evidence to support implementation will be provided to the PCO in the form of a report by no
later than 31 March 2013. The report should include the following information:
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
a summary of the details of the improvement plan

the action taken to help reduce avoidable A&E attendances

information on the three categories of patients (see above) and how improvements in
care and primary care access have helped reduce avoidable A&E attendance for these
patients.
If the data quality provided to the practice does not allow this to be done for all patients, then
this should be noted in the report with an explanation as to which patients the data are
missing and, if possible, the reasons why.
See page 8 for guidance on end of year report.
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Scotland
The end of year evidence required for Scotland will include the following:
1. Older patients with co-morbidities at high risk of admission (patients aged 65 years and
over) - care plan for high risk SPARRA patients (1/2500 registered list size)
Description of case review to include:

Internal Practice issues required to support reducing attendance

External to practice eg Social work, Secondary care issues required to support
reducing attendance

Any other issues/learning
2. . Children with minor illness/injury (patients aged 15 years and under)
Plan describing measures to reduce avoidable A&E attendances by this group to include:

Internal Practice issues required to support reducing attendance

External to practice eg Social work, Secondary care issues required to support
reducing attendance

Any other issues/learning
3. Patients who frequently re-attend A&E that could be dealt with in primary care
Description of case review to include:

Internal Practice issues required to support reducing attendance

External to practice eg Social work, Secondary care issues required to support
reducing attendance

Any other issues/learning
4. For men of working age in practices with no patients in 1 and 3
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Plan describing measures to reduce avoidable attendances in A and E to include:

Internal Practice issues required to support reducing attendance

External to practice eg Social work, Secondary care issues required to support
reducing attendance
Any other issues/learning
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APPENDIX A
Care Plan
Some care plans are mainly for community or hospital staff to highlight the best way to treat
a patient if they attend. Other care plans will be mainly to inform patients of how best to
access the advice or treatment they need when they feel unwell.
The areas below will not all need to be included in every care plan; it is up to the author of
the plan to pick and choose what is best for their patient.
The plan may be written by a GP or by another clinician who is involved with the patient for
example a CPN or practice nurse

Patient details

GP details

Details of any other staff or support/community agencies involved. Other
groups e.g. Community Learning Disability Teams, Mental Health Teams, Social
work or housing may be detailed here.

Details of any other family, friends or support staff willing to be contacted if the
patient attends A+E (both in and out of hours)

Diagnosis
Any significant diagnosis and operations the patient has had. It can be helpful to detail a
patients normal presentation or usual symptoms to help guide a clinician who may be
unfamiliar with the patient. In certain conditions it can be useful to list their normal baseline
observations e.g. COPD and oxygen saturations.

Medication – normally accessed through ECS but note any specific medication
issues eg avoid opiates

Investigations
Some patients have had lots of negative investigations over the years which can be helpful
to list as it may avoid these being repeated unnecessarily.

Background
If appropriate document where they live, who they live with. Any significant past medical or
social history. Also any details of where they get their support from and who they are closest
to. It can be helpful to list any particular stressors that may make it more likely for a patient to
seek help.
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
Guidance for patient
If a patient has a copy of the plan it can be useful to highlight what steps they can take
before attending either their GP or A&E.
This can be written by another team involved with them CLDT, Mental Health.
It can list the best person to contact in certain situations and this might not always be health
centres e.g. pharmacy, voluntary agencies, support staff who work with them.

Guidance during consultation
This is usually for the emergency department staff when they see the patient.
It may be medical and drawn up in conjunction with secondary care.
It may involve a description of their usual presentation or usual baseline obs (oxygen
saturation etc).
Or it may be based around their ability to read or understand or may be advice on how they
interact with staff.
If there are any concerns about them being seen alone or by a particular sex then that
should be recorded in this section.
Phrases that are used for patients with somatising or abnormal health seeking behaviour are




Treat the signs not the symptoms
Aim is to de-medicalise the problem
Aim is to reduce possibility of iatrogenic harm through over investigation
Please do not speculate on possible diagnosis
SUGGESTED PROCESS
Step 1: Draw up Plan
Step 2: Discuss with patient
Step 3: Review patients co-operation with the plan
Step 4: Further meeting if required.
Once a care plan is in place in some patients it is necessary to agree a contract with them
and to review this after a few months. It may state that they do not attend A&E for minor
injuries but use a different path specified in the plan. If they do not meet these requirements
then the practice could suggest a further meeting maybe with secondary care input to best
plan a way forward.
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