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Good Practice: Quality of Care - Our quality improvement plans

Professor Ruth Chambers reveals how the QIF scheme for Stoke-on-Trent evolved and is progressing.

Dr Chambers: QIF practices in Stoke-on-Trent receive an upfront payment from a pot of £500,000
Dr Chambers: QIF practices in Stoke-on-Trent receive an upfront payment from a pot of £500,000

The pros and cons of setting up local quality improvement framework (QIF) schemes to complement the national QOF have been discussed a lot, and opinion is divided.

Some PCTs favour balanced scorecards focusing on measurable components of practices' structure and processes.

Others - like my PCT, NHS Stoke-on-Trent - are investing in rewarding practices through a local enhanced service contract for achieving clinical outcomes above and beyond QOF incentives and targeted at redressing health inequalities.

NHS Stoke-on-Trent set up a primary care development unit (PCDU) to support its 55 GP practices in developing and delivering enhanced care through a QIF. The PCT allocated funding of up to £1.9 million for the period 2009 to 2012 to learning and development resources for practices, and to reward those achieving higher clinical standards.

Upfront payments
Qualifying practices can between them receive about £500,000 in upfront payments to enable them to employ more staff or to extend their hours and fund administrative help.

Our QIF scheme was put together in 2008 by a professional panel including GPs, the deputy director of public health, PCT managers and the QIF clinical champion. This was after considering the evidence base for the QOF and enhanced delivery of care, and weighting alternative clinical outcome indicators.

Consultation with all practices, the PCT's professional executive committee and LMC was extensive. The scheme will run for a minimum three years - hopefully for longer if the investment in enhanced quality of care proves justified.

The first stage was to offer a baseline assessment to all practices so they could show they were ready to enter the scheme.

After deliberating hard, the PCDU agreed the assessments would involve demonstrating achievements against a range of items describing the structures and processes in place in the practices, covering their core contract and reflecting best or exemplary practice.

Many of these items feature in various RCGP quality initiatives, and the Care Quality Commission is expected to adopt them when practices register in 2011.

The PCT is therefore supporting practices preparing for national accreditation schemes as well as helping to raise standards and minimise health inequalities.

Revalidation evidence
Reports about the quality of care provided by individual GPs should also aid them in gathering revalidation evidence.

The PCT commissioned the Collingham Healthcare Education Centre (CHEC), a not-for-profit social enterprise to create the assessment content and review each practice.

Led by Professor Mike Pringle, the RCGP's revalidation lead, the CHEC team collated practice attainment information from the PCT (using disease prevalence, PCT-wide audits and other data) and individual practices (using the currency of clinical/non-clinical protocols, patient participation groups, appointments available with GP/practice nurse in set time period, as examples).

Then a face-to-face review in the practice by a CHEC GP or senior practice manager validated information already supplied, or looked at other baseline items such as health and safety issues or how up to date protocols were.

All Stoke practices volunteered for the baseline review in January 2009. Six found they were breaching as many as 20 items in their core contract, and were offered support.

Six months later, three of the six had corrected their deficiencies so could join the QIF incentive scheme. By March 2010 the other three failing practices had remedied all core breaches.

The other 49 practices agreed a three-year practice development plan proposed by CHEC in May 2009, and have put in efforts to achieve the plan's clinical indicators (see box).

QIF in Stoke-on-Trent
Year one example of clinical indicators
IndicatorsTargetPoints
Hypertension
Percentage of patients (aged up to 80 years old) on hypertension disease register in whom at least two BP readings (measured in the previous 15 months and at least four months apart) are 140/90mmHg or less50%-plus
60%-plus
70%-plus
10
+5
+5
(20 in total)
Diabetes
A routine diabetes review service for normally housebound patients.
90%-plus
8
Obesity
Proportion of patients who have a BMI who have physical activity levels assessed using GPPAQ and BP recorded in past three years.80%6

Under the plan, a practice with a 10,000 patient list could earn up to £45,000 from scoring 110 points on the clinical indicators in year one.

If a practice seems an outlier in terms of a particular disease's prevalence, then it may have to demonstrate that its register is robust or the prevalence is correct for the demographics of its population.

Performance slip
Twelve months after the scheme was launched, most QIF scheme practices are making good progress with their development plans. But six of the practices (different from those initially excluded) let their performance slip and were judged to have 'failed' their end of year review in March 2010.

These six are now in the PCT's spotlight and are barred from the QIF incentive scheme until they redress their under-performance.

Stoke's three new Darzi practices (bringing the number of practices to 58) are expected to meet the aspirational QIF standards without incentives.

Overall, the QIF scheme in Stoke is a resounding success for general practice and is stimulating continuing quality improvement at the frontline.

  • Professor Chambers is a GP in Stoke-on-Trent, PCT clinical champion for QIF and honorary professor at Stafford University; www.stoke.nhs.uk, www.chec.org.uk

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