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Gold, incentives and meh

Battlelines drawn on exception reporting

By Daniel Cressey

Diabetes, stroke and mental health will be the key battlegrounds between PCTs and GPs over exception reporting rates, a Pulse investigation reveals.

An analysis of estimated rates for a selection of key indicators uncovers sharp differences between them ­ and wide variation between practices (see graphs, right).

Pulse reported last week that the Department of Health had signalled a nationwide audit of exception reporting rates in response to reports of 'gaming' in some practices.

But GPs complained they had received no national guidance over exception reporting rates and had no way of comparing themselves with the national average.

Clinical leads warned diabetes rates of over 10 per cent might raise suspicions, although they said high rates might be more expected with mental health.

In the Pulse analysis of QOF data, the highest average rate for exception reporting, excluding indicators for flu vaccination (see panel), was 13 per cent for epilepsy 4 ­ those 16 and over seizure free.

Stroke 8 ­ those with TIA or stroke with cholesterol 5mmol/l or lower ­ averaged 10 per cent, as did DM6 for patients with HbA1c less than 7.4 per cent.

By contrast CHD and hypertenstion patients with blood pressure 150/90mmHg or less ­ CHD 6 and BP 5 ­ had average rates of just 3 and 5 per cent respectively.

Dr Robin Hollands, a GP in Cheltenham and QOF lead for Gloucestershire LMC, said: 'This is certainly causing confusion for our GPs and around the country. In my experience there's huge practice variation and particularly in stroke, diabetes and mental health. The blue book guidance is not very specific. There needs to be more national guidance.'

Dr John Guy, clinical lead at North Essex's Education and Quality in Practice, said: 'Some idea of what national ranges are is very helpful to people.

'Most indicators are very achievable ­ if people are falling well out they would have to have strong reasons for explaining why. A bit more advice would be very welcome.'

Dr Stewart Findlay, a GP in Bishop Auckland, Co. Durham, and treasurer of the Primary Care Cardiovascular Society, criticised the exception reporting system. 'Exception reporting itself is a problem area. There's been no national definition ­ we do need guidelines on what is acceptable to report.'

Exception reporting for mental health indicator 5 ­ lithium in the therapeutic range ­ averaged 9 per cent, and more than a quarter of practices excepted over 10 per cent of patients.

Dr Lizzie Miller, a GP with a special interest in mental health in Fulham, west London, said: 'It's all quite new and it's an area of practice that hasn't really been looked at. It's quite a murky area.'

Dr Guy added: 'There are

patients who are actually

quite well controlled on levels that are smaller than in the QOF.'

Flu vaccination rates highest

Flu vaccination is one area where the high rates of exception reporting uncovered by the Pulse analysis had been predicted by experts.

Exception reporting rates for flu vaccination averaged 10 per cent in CHD patients, 12 per cent in stroke patients and 16 per cent in diabetes patients.

Dr John Guy, clinical lead at North Essex's Education and Quality in Practice, said: 'Areas where there's been big exceptions are where there's flu indication [eg] in asthma.'

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