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Introduction - Tackling the quality indicators

The QoF remains unchanged for 2007/8 after NHS Employers and the GPC were unable to reach agreement on any revisions to the nGMS contract this year.

Key points for 2007/8

  • Average exception reporting rates were released for the first time towards the end of the last financial year and could be the focus of greater scrutiny in 2007/8 (see below).
  • Practices will be able to use this year to refine their performances in indicator sets that were new to the QoF last year, particularly those that may have caused problems such as chronic kidney disease, mental health and depression.
  • The clinical domain accounts for 655 points of the 1,000 points available.

What will happen to the QoF after 2007/8

  • NHS Employers and the GPC began the process for revising the QoF at the beginning of 2007 by seeking evidence from patient groups and other organisations about potential disease areas to be included or revised in future.
  • NHS Employers is currently taking evidence from such bodies with the aim of producing a report for the QoF negotiating group by autumn 2007.
  • Possible changes could include new disease areas added to the QoF, existing sets revised to bring them all in line with guidance from the National Institute of Clinical Excellence wherever possible, indicators judged over 12 months rather than 15 and changes to on exception reporting rules.
  • The review could mean large scale revisions to the framework and changes may be introduced for 2008/9, although timing is uncertain as contract negotiations are currently stalled.

What it is worth in 2007/8

  • The clinical domain accounts for 655 of the 1,000 quality points available each year. The payment per point remains at £124.60 from April 2007, that means about £82,000 in 2007/8 for practices with the average list size.

The new contract year

  • Make sure the practice is up to speed on all new disease areas and has decided which of the indicator sets it will aim to meet and how.
  • Review your performance from 2006/7. Your results from last year should help you to identify weak spots. Practices that did not score maximum points in all disease areas last year may want to work out the costs and benefits of delivering maximum thresholds.
  • It is important to balance total workload against potential financial gain and identify where to review skill mix and training.
  • Bear in mind that PCOs are being encouraged to look increasingly carefully at practice results, focusing particularly on high and low scorers. In England last year PCTs were reminded that each QoF point cost the NHS £1million and to confirm and challenge QoF assessments at all stages.
  • Set targets for what you expect to achieve in each of the next 12 months in terms of patients seen and data entered.
  • Plan routine checks in the first half of the year, giving yourself time to work on poorly controlled patients in the second half. Before Christmas, review your performance against last year, this should highlight any disease areas or individual indicators that require more attention.

Disease registers

  • Practices need to be able to create disease registers for 17 of the 18 disease areas. The quality of these data is the key to success.
  • Practices with incomplete electronic records need to search to identify patients with Read codes, plus searching on relevant medication if appropriate and manually searching notes.
  • Creating registers should be straightforward if you have accurate electronic records. You will be able to select records by searching on relevant Read codes used historically.
  • Once the list of patients in each area has been data cleansed to make sure only patients with correct diagnoses are on each register, every patient should be coded.
  • Ensure all team members are using appropriate codes for each indicator and agree a system for screening hospital letters.
  • Prevalence is important. Average national data for last year's new indicator sets was already available for England and Northern Ireland as we went to press and the other two countries should release their data by the end of September at the latest. Data from all four countries for 2005/6 for the original disease areas is available. Check your registers against national and local figures to ensure you are on the right track.

Exception reporting

  • Exception reporting is intended to overcome objections raised about payment schemes where GPs are seen to be unfairly penalised when patients choose not to participate.
  • Exception reporting rates for 2005/6 have now been released. Overall average exception reporting rates for England in 2005/6 were 5.5 per cent with just over 5 per cent of practices having exception reporting rates over 10 per cent. Rates by indicator group are included in the step-by-step action plan for each disease area.
  • PCOs are expected to investigate exception reporting closely and will be particularly looking at practices with rates above average.
  • Develop a policy on exception reporting but be sure to balance the need to remove unsuitable patients from the register against possible claims of, at worst, fraud.
  • Practices must be prepared to discuss with assessors the clinical reasons why individuals have been excepted. Add free text explanations to exceptions wherever possible.
  • Note that non-attenders can be excepted if they have refused to attend three times. Patients are expected to receive an individually addressed invitation on each occasion. You might want to set up a system to send three recall letters to patients at monthly intervals.

Allowable reasons for exception reporting

  • Patients refuse to attend three times.
  • Patients are new* or recently diagnosed.
  • It is not clinically appropriate.
  • They have expressed informed dissent.
  • They cannot tolerate medication/therapy.
  • They are taking maximum medication.
  • They have another supervening condition.

* New patients can be exception reported at first but the criteria state they must have relevant measurements (such as BP) carried out within three months and delivery of clinical standards within nine months.

Practice organisation

  • Make sure all team members are aware of quality framework requirements and consider reorganising to improve care. Consider setting up subgroups within the practice to lead on individual disease areas. Depending on the size of your practice, a team of a GP, a nurse and an administrator can be nominated to tackle particular areas.
  • If you do not have an IT specialist, consider recruiting one. Effective use of IT is essential.
  • Receptionists can be trained to take bloods or measure BP and healthcare assistants can be recruited to relieve nurses of some tasks.
  • Involve the team in the practice’s goals and reflect this in your patient material.
  • Make sure you are using national Read codes and that templates are in place.
  • Look at expert patient groups and disease specific support groups that may help with more challenging patients (see box below).
  • Systems for hospital data capture are vital when indicators require information, for example, echocardiograms carried out in hospital. This need for specific information from secondary care may create conflict. Consider local liaison groups to identify problems and solutions.
  • Use audits to identify strengths, weaknesses and risks. Measure all consulters and provide generic feedback on performance. If patients are not being treated to targets, or smoking status and medication reviews are not being updated, you may have to consider consulter-specific feedback.

Key areas

  • There are key clinical areas across indicators and similarly, key patients who fall within more than one indicator, for example, a patient may be on the hypertension and the diabetes register. Correct management of key patients and areas will bring rewards. However, do not lose sight of individual patients in the pursuit of quality points. Where patients fall into more than one disease area, make sure that all checks are carried out in one visit.
  • Smoking is one key area worth 68 points in the clinical domain and a further 13 in the organisational indicators. Influenza immunisation is another key area, worth 18 points within the clinical indicators and also a directly enhanced service.

Holistic care payments

  • Originally designed to reward breadth of achievement in the clinical domain, holistic care payments were substantially reduced for 2006/7, down from 100 points to 20, as part of the deal to allow the inclusion of new clinical areas.
  • The number of holistic care points earned is equivalent to the third lowest proportion of points earned across the domains, for example, if the practice’s third lowest proportion were 25 per cent of points for asthma, 25 points would be earned.
  • Scoring points in 16 of the 18 disease areas will mean the practice is eligible for up to 20 extra points under holistic care payments.

Useful Links

1. Exception reporting guide
2. Expert Patient Programme
3. BMA Quality and Outcomes Framework Guidance

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