Closing the gap-finding the missing thousands

A service run across a CCG/locality/group of practices to help identify and include appropriate patients on practice QOF disease registers to help address health inequalities. We pro-actively seek people who already have diseases who are not included on practice QOF registers to ensure they are offered services appropriate to manage their conditions.

Many CCG’s are aware many of their practices have low prevalence in areas where, for one reason or another, they expect prevalence to be high. This is most often due to inaccurate coding in primary care – commissioning of services is impossible if you don’t know the true make-up of your population.

So, how can our multi-practice QOF register optimisation service help?

  • QOF register validations were carried out across 22 practices (CCG) with a total population of 176,000 patients
  • More than 18,000 patients were identified as ‘missing’ off one or more QOF disease areas
  • Following practice engagement, initial follow-up identified registers had actually increased by more than 5,200 patients
DiseaseOverall % increase
Diabetes178% *
HF due to LVSD284% *
Mental health58%

*on-going education with practices and specific CCG focus helped to increase registers substantially more due between the initial audits and follow-up stage.

To discuss how we can work with you and your local practices to help bridge the gap and address health inequalities, please contact us on 01527 557407 or email

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