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Chronic disease management: will it help patients and GPs?

Chronic disease management is one of the key areas of the proposed new contract.

Dr Lorna Gold examines the proposals, looking at the good points, the bad points, and asking whether GPs will benefit

he current chronic disease management arrangements are chaotic. GPs' desks are sagging under the weight of locally and nationally produced guidelines and protocols, few of them sensitive to the needs of individual patients or practices. It is hoped that the new contract will improve matters. A nationally standardised and funded programme should be fairer and more transparent than the present scrappy system.

Chronic disease management will be classified along with immunisation, contraception, child health surveillance and cervical cytology as an Additional Clinical Service. Most practices will be expected to provide such services, and there will be no scope to opt out unless there are exceptional circumstances such as a shortage of clinical staff.

Until now, chronic disease management payments have been restricted to a small number of conditions, typically asthma, diabetes and cardiovascular disease. Under the new contract, GPs who have an interest in a wider range of conditions, such as epilepsy, depression and rheumatoid arthritis, will find their skills better rewarded, and GPs with specialised skills may be able to provide Enhanced Clinical Services to their own patients or within the PCT. Payment for all of these services will be in addition to the practice's share of the global agreed sum.

Patients should benefit. Those with chronic diseases such as epilepsy and hypothyroidism may find that their GP takes more interest in their care. Our care of patients with cardiovascular disease, and possibly other conditions, will have to follow evidence-based guidelines if we are to achieve quality markers. Recall systems and recording of information should improve.

Big Brother will be happy too. Patients will have nationally applicable benchmarks with which to assess their GP's level of interest and expertise in meeting their particular health needs, and information gathered in this way will provide raw numbers which the Government can use to rank GPs in league tables.

What are GPs expected to do?

Above all, do not be alarmed by the document's resemblance to Virginia Bottomley's notorious health promotion banding scheme. GPs do not have to do everything at once. Payment will be made in advance and will be based on what practices expect to be able to achieve rather than on what we are currently achieving.

Our performance will be judged against three sets of benchmarks:

 · Organisational quality markers

These will be banded into three levels and will cover areas such as the provision of disabled toilets, the existence of a practice health and safety policy, and the quality of record-keeping.

 · Tiered clinical quality markers

These will also be banded into three levels and will cover a wide range of clinical conditions. An additional and very high premium payment is promised for practices achieving the highest level of care across a range of markers.

 · Phased clinical quality markers

Some conditions ­ cardiovascular disease is given as an example ­ are too complex to be broken down neatly into three tiered markers, and a five-stage scale, with incremental steps within each stage, will apply. Levels 1 and 2 are organisational targets and most GPs will recognise them as being very similar to current PCT-based incentive protocols. By level 3, financial incentives start to depend upon measurable clinical outcomes such as the percentage of patients whose blood pressure or blood lipids are at a level decreed by national evidence-based guidelines. Once the optimum level 3 standard has been achieved, the practice will qualify for level 4 payments and need do no more than maintain its performance. However, practices achieving the highest standard of care across all quality areas will advance to level 5 and receive substantially higher payments.

This scheme could be a poisoned chalice for GPs and patients. GPs will not receive funding to remain at level 1 or 2 indefinitely, but our progress beyond the bottom step of level 3 will depend upon whether our patients take, and respond to, their statins and ACE inhibitors. Who among us would never be tempted to reach for a removal form if one patient's refusal to take medication would mean a large drop in our income? In recognition of this, the document includes provision for exception reporting, or excluding from the statistics, those patients who have declined treatment either explicitly or by default, who cannot tolerate medication, who are not responding adequately to maximum doses of medication, or whom it is inappropriate to treat due to other medical conditions such as liver disease or terminal illness.

The other commonly expressed concern is that GPs and staff will have to spend a lot of time entering data on computer. Unfortunately, the document itself and information leaked subsequently provide no reassurance on this issue.

The new contract executive summary tells us that:

 · GPs will be rewarded for the quality of service they offer to their patients.

 · A graded scheme based on incentives and rewards will encourage practices to move up the quality ladder.

 · The scheme will be based on high trust, low bureaucracy principles.

 · Safeguards will be there to stop practices being penalised if patients refuse treatment, don't respond to treatment, or do not take advice.

 · Over time the quality scheme should lead to longer consultations with patients.

Next week:

the new contract's proposals for essential clinical services and


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