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Quality framework - Annual review with a prescribing adviser

Plan ahead and suggest targets, advises Dr Jeremy Phipps.

The QOF year starts in April and with it comes the annual meeting with your primary care organisation (PCO) prescribing adviser to set targets for the next 12 months.

Schedule your meeting for as early in the QOF year as possible to leave time to meet your targets (Photograph: Getty images)

This meeting is to agree goals for the year (Medicines Indicator 6) and to provide evidence that progress has been made towards last year's goals (Medicines Indicator 10). It has been part of the QOF since its introduction in 2003. There are a total of eight points at stake.

Unfortunately, many practices feel these targets are imposed upon them rather than mutually agreed, although this need not be the case.

In addition, any dispensing practices feel they are particularly targeted due to the mistaken belief that they are profligate users of NHS resources.

It is therefore vital that dispensing GPs ensure any changes in prescribing behaviour are transparent and for the good of patients, even if, coincidentally, they generate increased profit for the practice.

Setting targets
Schedule your meeting for as early in the QOF year as possible. Planning it for September, and initiating the necessary actions with only six months remaining, will only make targets harder to meet.

Most PCO prescribing groups will have clear goals they wish to achieve in the forthcoming year. These may reflect national priorities but it is likely that proposed targets will also reflect local initiatives related to current prescribing.

Although targets will be suggested, some practices do not realise they can also put forward their own.

Detailed knowledge of your patients can prove invaluable here, especially if there are particular issues affecting the local population that your suggested targets might address.

Note that some prescribing advisers allow more than three agreed actions, providing greater scope for the practice to make its own suggestions, and permitting the practice to achieve by succeeding in any three of the agreed areas.

Targets will need a good evidence base to support their inclusion but should involve a change that can be easily measured to ensure compliance.

Preference will be given to changes that can be demonstrated through a robust mechanism such as data from the NHS Business Services Authority (NHSBSA), the new resource for accessing practice prescribing information.

Bear in mind your time pressures and try to keep changes simple, aiming for clinical areas that include a relatively small number of patients. Ideally, changes should involve work that the practice would be undertaking anyway.

For example, in the first year of the QOF, my practice was fortunate to have set 'reduction in co-proxamol use' as a target, shortly before the virtual withdrawal of this medicine from the market.

Although prescribing quality is important, prescribing advisers are under pressure to reduce the ever-increasing drugs cost for the NHS. Using more cost-effective PPIs and statins is consequently a frequent target, although this may no longer be the case with the former, since esomeprazole and pantoprazole come off patent this year.

Dispensing practices have the extra complication of not wishing to damage their businesses, and so need to consider the bigger picture.

For example, last year, our PCO wished us to prescribe lower cost bisphosphonates. We used this as an opportunity to study our prescribing in osteoporosis, using cheaper alternatives but also ensuring we co-prescribed calcium and vitamin D supplements.

We were able to improve care for patients, reduce our spending on bisphosphonates but also increase the number of dispensed items.

Over the past couple of years, safety alerts have been produced for different medicines, often through the MHRA. Making changes as a result of this advice is a sign of quality prescribing.

Often this will entail a change in a patient's medication to safer alternative (as discussed with them), but with no loss in overall dispensing.

Two of our targets in the past two years, relating to safety, have involved dosulepin and minocycline. The numbers of patients involved were small, with simple switches during routine consultations to safer medicines.

Signed agreement
After your meeting with the prescribing adviser, a document explicitly listing the targets should be signed by both parties. This allows any confusion as to what was agreed to be identified at the outset, and resolved.

Ideally, the practice should have a clear plan for how it intends to move toward these targets, and the PCO should provide resources to aid computer searches and the sending out of standard letters to patients.

I would encourage practices to name the PCO at the top of any correspondence to patients and to state it as a point of contact. This helps to legitimise any proposed change in medication and simplifies contacts for any patient who is concerned about the change. Letters should be clear, unambiguous and free of jargon.

Medication changes to safer alternatives are generally easy to justify to patients, however changes made for a stable patient, purely to lower costs, are harder to explain.

There are increasing worries that standard PCO letters fail to obtain full informed consent because patients' medications are automatically changed unless they explicitly disagree.

Many GPs now insist that any switch can occur only if the patient replies to state that they have understood and agreed the change in medication. If there are concerns, the BMA advises GPs to seek guidance from the local ethics committee.

  • Dr Phipps is a dispensing GP in Lincolnshire
TIPS
  • Meet with the prescribing adviser early in the QOF year.
  • Set a finishing time for the meeting: discussions can drag on.
  • Have a written agreement for at least three targets.
  • Aim for targets with low patient numbers.
  • Plan early on how you will achieve your targets.
  • Make use of PCO resources.

 

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