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At the heart of general practice since 1960

High QOF scoring practice gets fraud visit

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case History

You've been fairly satisfied with the Quality and Outcomes Framework. Your practice achieved almost 1,000 points last year and although there is still work to be done tightening up on blood pressure levels and so on, you are confident the computer prompts will lead to an improvement this year.

You are shocked, however, when the QOF visiting team tells you that you have an unusually low prevalence of several key diseases including diabetes, hypertension and COPD, compared to other practices in the PCT. They suggest you are failing to seek out and recognise morbidity; you have an uncomfortable feeling that they suspect you may be omitting cases from your chronic disease registers because they don't meet the targets. What should you do?

1. View from Dr Nigel de Kare Silver

It is easy to be reflexive here and claim absolute innocence and maligning. However, there are serious issues and serious allegations even though these may not be overt at the moment.

General practice achieved a bad reputation at the end of the 1990s thanks to very few rotten apples but compounded by the single worst doctor of British history, Shipman. The new contract was a sprat to catch a mackerel. For a small pay increment, the Government has achieved what none before managed : to tame doctors and bring in an inspection system. In as much as doctors have scored so highly on the points it is clear that across the UK we have the talents and skills to deliver a high class medical service and probably provide the best primary care within Europe. The payback is acceptance that payment may depend on inspection. Nevertheless, in any organisation working with a large number of people there is an assumption that some rotten apples will remain and as unpleasant as is, verification by inspection is part of that process.

An audit to uncover fraud is frightening. It is highly likely your practice has been singled out for some reason and, as much as one may be angered the initial approach, it is important to take an open and honest attitude with the inspection team. In a 4,000-patient practice there will be at least 80 patients with diabetes or even double that. Once numbers reach this size it is likely that one or two patients may be incorrectly labelled. Do not attempt to hide these as it will only be used against you.

Do all you can to protect yourself at the outset. Ensure your whole practice team knows how to record all disease categories within QOF and that these are consistent. Use your clinical meetings to ensure everyone understands the importance of using correct codes and make sure your induction for all new clinical staff includes IT sessions on coding and especially coding within QOF.

GP Nigel de Kare Silver is a course organiser and trainer - and part of a practice scoring more than 1,000 quality points

2. View from Dr Tonia Myers

QOF visiting teams seem to be more to pick fault with practices that aspire to excellence, than to root out true fraud. I would show genuine surprise at the supposedly low prevalence, but be extremely indignant at any implication that any potential ‘under-diagnosis' might have been deliberate.

The visiting team are only doing their job to point out the discrepancy. It is possible the PCT's prevalence data is wrong or that the practice is actually demographically different in some way to other practices in the PCT. If there is no obvious difference, the practice should agree to review the disease registers again to check if they are indeed inaccurate, perhaps because of a problem with the Read codes we are using. In a relatively small practice it should be easy prospectively to ensure consistency with data entry, but there could be patients with ‘ancient diagnoses' who were coded using old read codes that have not been picked up on our computer searches.

In our practice when the disease registers were drawn up, with the exception of COPD for which we had an unusually low prevalence, we felt our problem was over-diagnosing hypertension and asthma by entering diagnostic codes when a diagnosis was only suspected and had not yet been confirmed.

Nevertheless, the lists need to be checked again and further computer searches need to be done for example to ensure that all our patients taking medication for these conditions have a searchable Read code on their records. In this task, I would enlist the help of our computer software supplier, who already helpfully puts a yellow QOF flag against certain Read codes, so we use correct codes for new diagnoses, to avoid this problem recurring.

As there was no misdoing, the practice should not fear closer investigation. If its figures were wrong then they should be corrected. If not, I doubt we will get an apology. I would point out to the team that we had not by any means scored maximum points and that our ‘exception rate' was not high. I would also express the hope they would scrutinise practices with high ‘exception rates' as thoroughly as ours.

Dr Tonia Myers is a GP in Highams Park, London

3. View from Dr Alison Lennox

This future has arrived. It has taken until 2007 to get to 1984. The Thought Police have come to arrest us. It is quite difficult to omit people from the diabetic, and hypertensive disease registers if they are on regular medication because the machine keeps prompting regular checks.

There are lots of reasons why a practice may have different demographics from its neighbours .Either you have been deliberately taking people off the registers because they have been lowering your targets or you haven't. If you have, it is fraud and you should be sanctioned accordingly. If you haven't done anything wrong intentionally and the PCT think you have, then you need to agree a checking process.

I think that the whole QOF system is bound to implode very quickly in the current climate. The Government has decided GPs are paid too much. This means PCTs are looking hard to challenge QOF payments. It is clear that year on year targets are going to be set at impossible levels, this means increasing incentives to massage figures or to just give up altogether.

It is a shame because the basic QOF idea was a good one. There are many problems with setting very high goals as treatment becomes target orientated rather than patient centred. I wonder at the current trend for putting very, very, elderly type 2 diabetes patients on insulin. They often end up living on dextrose because they are so worried about having ‘hypos' their weight increases, their insulin dose goes up they eat more and round and round we go. When we were allowed their sugars to 'run a bit high' they used to carry on pretty much as normal. I'm sure that this is driven partly by the obsession to get the HbA1c below 7 per cent which of course is very important and appropriate for most but not all patients with diabetes.

We are now seeing the downside of statins. They are wonderful at lowering cholesterol and probably significantly lowering the risk of MI and strokes in many, but increasing numbers are recognising, sleeplessness, abdominal pain and, most of all, muscle pain and weakness while on these drugs. Targets have their place but we are doctors for a reason: we must treat our patients and not government statistics.

Dr Alison Lennox is a GP locum in Staffordshire

Learning points

What does this incident teach us?

QOF

• Quality and Outcomes Framework was introduced as the core of the new General Medical Services contract for GPs in April 2004

• QOF refers to a system of payment by results whereby GPs are paid according to their ability to reach certain targets

• There are 3 main sections – Clinical, Organisational and Patient Experience

• Keeping disease registers form a key part of the clinical section

• The GPC agreed with the government at the contract's inception that new domains could be introduced and targets changed every two years

• Maximum number of points achievable under QOF in 2007/8 = 1,000 points

• Diabetes (99), hypertension (105) and chronic obstructive pulmonary disease (45) all represent significant points

• In 2005/6 the average score achieved by practices in England was 1,010.5 (out of the 1050 points which were then available)

• Practices are asked to submit self assessments of their achievements – the PCT will then arrange a QOF visit to a random selection of practices (sometimes selected by an LMC ballot) and may also choose to visit, or at least make enquiries of, any practices whose figures seem at significant variance from the PCT norm

• Ensuring all clinical staff use appropriate Read codes for diseases can help to maximise QOF points – this can be aided by the use of templates and QOF management tools

• Practices can exception report patients either from whole domains by virtue of them being unsuitable or informed dissent or from individual targets, for example those already on maximal tolerated medication but still not at target, or where a specific service is not available

• Practices can choose to opt out of any aspect of QOF if they perceive the effort required to achieve any given points is greater than the financial reward received

Prevalence rates

• Prevalence rates vary significantly between and within PCTs depending upon the demographics of the population studied

• Average prevalence rates in Gloucestershire are:

o Diabetes mellitus – 3.5%

o Chronic Obstructive Pulmonary Disease – 1.5%

o Hypertension – 12%

• Practices that expect a deviation from the local norm, perhaps due to having a large student population or an institution such as an army barracks, should explain this.

GP Pay

• The Association of Independent Specialist Medical Accountants were quoted as claiming that some GPs in the UK earn up to £250,000 – a figure widely quoted by the media

• The BMA quotes the net average income for a self employed non dispensing GP in England for 2004/5 is £95,000

• On average GP pay has gone up by approximately 20% since the introduction of GMS

• There was no inflationary uplift to GP pay in 2006/7 and the GPC agreed ‘efficiency' changes to QOF which equated to approximately 15%

• As yet there is no agreement on pay for 2007/8

• Unit cost of each face to face GP consultation is £21

Dr Mandy Fry is a VTS course organiser in Oxford and a senior lecturer in primary care at Oxford Brookes University

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