Cost-effective use of Read codes will boost new contract income
Paul Cundy is co-chair of the GPC IT joint committee and a GP in Wimbledon, south-west London
Think twice before investing time and energy in a target which requires entering a lot of Read codes for little financial return, says Dr Paul Cundy
The best GPs have always been able to prioritise and this will be more important than ever with the quality and outcomes framework.
In particular it will pay GPs to box clever with the Q&O Read codes. The framework is evidence-based and this is reflected in the scoring system. The number of points per domain and the number of points per target are all different.
Take the clinical domains. This is where most of the points lie and the domains all have varying numbers of individual targets. Hypertension has five separate targets, diabetes has 18 but cancer has only two (see table 1 opposite, column 1).
Next take a look at the number of points for each target (column 2). Each target is weighted, the weighting reflecting the evidence-based relative importance of the activity. The 'targets per domain' varies and the 'points per target' varies.
The hypertension domain has five targets that can attract a total of 96 points. But mental health has a much smaller total of 41 points for the same number of targets. In diabetes you can earn three points more than in hypertension but these are spread over a massive 18 targets, a full 13 more than for hypertension.
What it boils down to can be seen in table 1, column 3 the points per target column. This is the average number of points scored for each target in the various domains.
It is easy to see that hypertension is the clear winner with 19 points per target, closely followed by asthma and coronary heart disease. Diabetes on the other hand scores a lowly five points and epilepsy and stroke and TIA a measly three points per target.
Remember that points equals cash under the Q&O framework. Indeed you can reread 'points per target' as 'pounds per target'.
Let us look at the hypertension domain (the individual targets for hypertension and the number of Read codes they need are set out in table 2).
The first target is to have a hypertension disease register. The next target is smoking status. All the latter needs is a second coded entry chosen from the various smoking codes.
The third target is satisfied if there is a record of whether patients have had smoking cessation advice. Another simple coded entry.
Target four requires a coded record of a blood pressure. But note it is any blood pressure. It does not matter whether it is 200/110 or 120/60 both will count towards this target.
So for the first four targets of the hypertension domain all you need are four separate Read codes per patient; a diagnosis code, a smoking status code, a smoking cessation advice code and a blood pressure code. Having these will earn you 49 points.
The fifth target needs no extra codes because it is a qualitative target. It is derived from the values of the blood pressures recorded under the fourth target. If the BP is less than 150/90 you earn extra points. So the coded entries for the fourth target also contribute towards the fifth.
Let us relate this back to the average GP. On the average list you might have between 100 to 200 patients with hypertension. To take a worst-case scenario, let us assume you have
200 hypertensives and that none of them are adequately controlled.
At four Read codes for each patient that's 800 coded entries needed to gain full points for the first four hypertension targets.
Why bother? Here's why. Points equals cash. The 49 points you will earn for the 800 codes will be worth £3,675 in 2004/5 and £5,880 in 2005/6. That's £7.35 earned for each coded entry. How long does it take you to type in a code? Isn't keeping a clinical record what you are supposed to do anyway? I can easily record five or more coded entries during any consultation and I will have no trouble whatsoever in getting all four codes down whenever I see a hypertensive which will be worth at least £28.
But remember the example I have given is a poorly performing doctor whose hypertensives are all out of control. Better-performing GPs will earn substantially more. Indeed, if the GP is a miracle worker and all his patients qualify for target five then he will earn £14.40 for each of the 800 codes in his records.
Now let us compare this with another Q&O target a record of smoking status in 55 per cent of patients aged
15-75. This is an all or nothing target that earns six points.
On my list I have 1,518 patients aged 15-75: 55 per cent equals 834 patients. One code per patient equals 834 coded entries. These 834 entries earn six points, so for 2004/5 that's £450 rising to £720 in 2005/6. Divide by the number of codes and that's a princely 86p per coded entry for 2005/6 with 2004/5 earning just 53p.
So on the one hand we have hypertension earning between £7 and £14 per coded entry and records target 10 earning at most 86p. Food for thought.
1 The clinical domains: Targets, points, points per target
Targets, points, points per target
Targets Points Points/
· Coronary heart disease 15 121 8
· Stroke and TIA 10 31 3
· Hypertension 5 96 19
· Hypothyroidism 2 8 4
· Diabetes 18 99 5
· COPD 8 45 5.6
· Asthma 7 58 8
· Epilepsy 4 12 3
· Mental health 5 41 8
· Cancer 2 12 6
2 Hypertension domain: Individual targets, points available, number of Read codes required Target Points No. of codes l'Disease register' 9 1
Individual targets, points available,
number of Read codes required
Target Points No. of
l'Disease register' 9 1
· Smoking status recorded 10 1
· Smokers offered cessation
therapy 10 1
· BP recorded last nine months 20 1
· BP 150/90 or less in last
nine months 56 0
Hypertension domain: Examples of earnings that can be achieved
Examples of earnings that can be achieved
Targets 1-4 achieved
Smoking status recorded, cessation therapy offered and BP recorded in last nine months. Four codes per patient.
Assume 200 patients with BP
Total 800 Read codes scores 49 points
£120 per point for 2005/6 = £5,880
£5,880 divided by 800 codes = £7:35 earned from each code
Now add in some adequately maintained patients
Assume 50 per cent BP less than 150/90
Earns an extra 28 points
New total points = 77 points
£120 per point for 2005/6 = £9,240
£9,240 divided by 800 codes = £11:55 earned from each coded entry
Now add in some very well maintained patients
Recalculate with 100 per cent BP less than 150/90
Earns a total 96 points
£120 per point 2005/6 = £11,520
£11,5240 decided by 800 codes = £14.40 earned from each coded entry