Getting to grips with the quality framework
The quality framework is complicated
and bureaucratic and the most successful practices will
be those that
get the basics right, says
Dr Anthony Lamb
The new contract's quality framework will introduce an unprecedented level of testing, monitoring and prescribing. My hope is that it will be simplified as time goes by, but in the meantime GPs will have to deal with it as it is.
The successful practices will be the ones that get the basics right, concentrate on essentials and don't waste time and effort. The following will need to be given priority status for any sort of success under the quality framework:
· Get a competent practice manager, a cohesive practice team, able staff of the right grade and good IT infrastructure and support. These are the foundations that underlie your future success.
· Look at your skill mix. Decide who is going to do what and address training and recruitment issues now. Doctors are not exempt from this process. Income will be related to computer use so make particularly sure you get your IT, recall systems, disease registers and so on right.
· Delegate to the least-qualified members of the team who can safely perform the tasks in hand. This will reduce costs and free up more expensive staff for jobs appropriate to their grade. Health care assistants and phlebotomists may prove the most useful additions to the team.
· Review total practice activity and consider dropping under-funded activities and medical hobbyhorses. You won't have time for them.
Plan how you will approach the framework
· Decide on which of the 10 clinical domains you will concentrate. For example, by disregarding the mental health and cancer domains (which I think are the most unattractive) you will only miss out on a maximum of 10 per cent of the total clinical points available. This still leaves 497 points available, making almost £60,000 for the notional average practice by 2005/6 (at £120 per point).
· Ignore no more than two clinical areas or you will miss out on the bonus holistic care payment that is determined by your performance in the third worst clinical area out of the 10.
· Highly structured, protocol-driven clinics with use of computer templates are the easiest and most reliable way of delivering the goods. Make sure all data is Read coded.
· Even within the context of clinics, patients will need a reasonable choice of slots if attendance is to be maximised. Some practices may find mixed clinics are the best way of achieving this.
· While it will be necessary for the health care assistant or nurse running a clinic to consult a GP where the protocol indicates, this does not mean the patient must always see a GP. Many issues may be resolved by a quick phone call or head-round-the-door exchange.
· Consider opting for an immediate consultation with a GP running a parallel surgery rather than risk the patient not coming back.
· Follow-up appointments for patients not meeting targets should be at intervals sufficient for any medication changes to take effect. A nurse or health care assistant could do this, a doctor being available for further consultation if required.
· If the practice prefers a doctor to do the follow-up appointment it should be with one who can be relied on to use the computer to input data.
· Avoid wasting valuable appointments flogging a treatment-resistant horse. Where permissible, exception reporting should be invoked to avoid open-ended struggles with lost causes. A single motivated and knowledgeable GP might act as a point of referral for difficult cases.
· Devise an effective way of dealing with housebound patients. There are no extra funds in the contract for home visits, and home visits are often required for patients with CHD, stroke, diabetes, COPD and so on. So the pressure will be on to reduce this supreme time-waster. If the patient cannot be persuaded or is unable to attend, the best solution is to enlist the help of the district nursing team.
They will need a paper template, the data from which can be transferred to the computer afterwards. Most therapeutic manoeuvres can then be made by remote control.
Example: the essentials of managing hypertension
There are 105 points available for hypertension management,
meaning £12,600 per notional average practice by 2005/6
Fortunately this area at least is fairly straightforward. Anyone with diagnosed hypertension should be recalled six-monthly (allowing three months extra to chase up defaulters) and the following simple protocol followed. No more than five minutes per appointment should be needed, and it should be within the capabilities of an HCA.
1 Has smoking status been recorded? If not, record it.
2 Has the giving of smoking cessation advice been recorded? If not, do it (leaflets are useful time-savers here) and record it.
3 Record BP. Is it 150/90 or less? If not, consult GP.
Note that the smoking data needs be recorded on a single occasion only; there is no requirement to interrogate hypertensive patients every year
(unlike vascular and diabetic patients).
Follow-up appointments should be at 4 to 6 week intervals, until control is achieved or an exception declared.
The following perversities
are worth noting:
· There is an incentive to diagnose hypertension at the lower end of the mercury scale, where reaching
150/90 is easiest. Will we see an escalation in diagnoses of mild hypertension?
· Conversely, unfortunately there is a disincentive to diagnose hypertension at the more difficult-to-control end of the scale.
· Traditional 'treatment' by lifestyle changes may be bypassed under pressure to achieve control and claim the points.
· There is no added incentive for achieving BP control beyond the marginal.
· Once the patient has had one reading of 150/90 or less, you risk losing your quality payment if you check it again that year and it has gone up!
· There is much scope for observer 'errors' when reading the scale.
· There is no added financial incentive for cholesterol testing in these patients. As practice resources are stretched by the test-fest demanded by other areas of the framework, this may be a luxury many practices decide they can't afford. Primary prevention could be marginalised as a result.
This mounting pressure on phlebotomy services may also influence drug choice. In the absence of CHD or DM, why choose an ACEI, which requires blood test monitoring, when (for example) ?-blockers and calcium blockers don't?