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GP contract - Quality scheme compliance checks

Dr Jeremy Phipps explains what to expect if a post-payment verification team pays your practice a visit.

Being informed by your primary care organisation (PCO) that your practice is to have a quality and outcomes framework 'post-payment verification' visit (PPVV) may fill you with dread. Rest assured. The visit is unlikely to be a huge ordeal.

When the quality framework was introduced four years ago, PCOs initially visited GP surgeries to explain how to comply with the rules for earning quality points and how to make payment claims. The scheme regulations also allow PCO teams to visit practices to ensure compliance.

Visits rationale
The DoH's guidance is for PPVVs to be made to a random 5 per cent of a PCO's practices each year. This is to ensure practices continue striving to comply with the quality rules as a predictable pattern of visits could lead to complacency.

PCOs should give practices at least three weeks' notice of the intended date of a PPVV.

These visits are covered by the same rules as standard annual quality scheme visits: the verification should be 'high trust and low touch'. The guidance says PCOs 'will not expect or be expected to conduct detailed or intrusive verification procedures, unless they suspect that incorrect figures may have been returned, or where there is suspicion of fraud'.

Verification team
The PCO's visiting group will usually consist of a clinician, a PCO manager with a good knowledge of the quality framework and often, another PCO staff member whose IT skills enable them to 'interrogate' the practice's computer system.

Other members of the team may include a lay member of the PCO board and someone from its a public health department.

Practice team
During the PPVV, the practice should make available the team members most involved in its quality scheme work - usually the practice manager, senior nurse and its quality framework lead. The PCO normally provides a timetable for the day and it is best if the whole practice team reduces or postpones commitments away from the surgery on visit day. There is no extra funding to cover staff time.

Clinical indicators
Part of the purpose of a PPVV is to check overall compliance with the rules for the different clinical domains. The time period the PCO team will consider is the preceding year, not the current one. If your practice is selected for a PPVV this year (2008/9), the team will check compliance with last year's (2007/8) quality rules. It is because this time lag can make checking computer records difficult that one of the PCO team is often an IT expert.

The practice's claim for quality points achieved will be compared with the average for other practice's in the PCO's area and with the national average.

Prevalence factors
The PCO's public health department carries out the comparisons and analysis based on the national average prevalence factors for your part of the UK.

It makes sense to compare the practice's results with these factors before the PPVV to help you to justify any differences.

Some variation is to be expected and occasionally anomalies arise that initially appear suspicious but which can be easily justified. I used to do PPVV work and was once asked to assess a practice where high epilepsy prevalence had been noted.

The practice explained that it provided medical services to a large residential home caring for patients with learning disabilities. Many of these patients had a dual epilepsy diagnosis.

Organisational indicators
Scrutiny of the practice management domains should be relatively straightforward. The PC0 team will usually wish to study the 'grade A and B' evidence.

This is information on areas such as protocols and job descriptions. The practice should have submitted the grade A data to the PCO before 31 March for the relevant year and should make the grade B data available during the PPVV.

The PCO team will usually study the annual patients' survey as a high proportion of points can be scored for this.

Countering fraud
The PCO team's job is to look for compliance. However, the NHS Counter Fraud & Security Management Service in England (CFSMS) or its equivalent elsewhere in the UK may advise PCOs in non practice-specific terms of potential concerns.

If at any stage during a PPVV fraud is suspected, the PCO team should leave and contact the CFSMS (or its equivalent). NHS counter-fraud investigations are rare in general practice but a separate counter-fraud visit may be made if initial suspicions seem credible.

  • Dr Phipps is a GP in Lincolnshire

Variations the PCO team will focus on

  • High levels of exception coding.
  • Abnormally high or low levels of disease prevalence.
  • Disproportionate variations in data entry during the year, especially near year-end.
  • Abnormal changes in data entry year on year.
  • Higher or lower levels of achievement than expected.

Visit www.healthcarerepublic.com/medeconomics for UK average disease prevalence factors for 2006/7 (averages for 2007/8 are due to be published soon)

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