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Joined-up care cuts workload in chronic disease

Dr David Lyon explains how practices could cut aspects of their chronic disease workload by up to one-third by taking into account patients with more than one condition

The new GP contract, and in particular the quality and outcomes framework (Q&O), offers strong clinical and financial incentives for practices to deliver good chronic disease management across a range of diseases. The research evidence on which the recommended targets are based is clearest for coronary heart disease (CHD) and diabetes.

Services need to be shaped around the patient, especially when a number of clinicians are involved, such as in diabetes, or when a patient suffers from a number of different diseases. This is particularly pertinent when conditions commonly overlap such as CHD, heart failure, hypertension, stroke and diabetes. These latter five diseases account for 356 of the 550 points in the clinical domains – nearly two-thirds. As the diagram on page 46 illustrates, several of the indicators are replicated across each of these conditions.

It is better for the patient if all their health checks are carried out at the one appointment. If a patient has diabetes, CHD, stroke and hypertension, a practice can carry out a single check-up using the templates already on the clinical systems supplied by the software providers and have that patient count four times towards points in the Q&O.

First, the diabetes template is completed; then all the CHD indicators will be already completed, apart from CHD9 aspirin and CHD10 ß-blockers.

All the stroke and hypertension

indicators will then automatically have been carried out.

Similarly, if a patient has CHD, stroke and hypertension, their data can be collected once and count three times. Start with the CHD template and continue as above. If someone has had a stroke and is hypertensive, start with the stroke template.

The only indicators that will not be satisfied following this methodology are the diagnostic tests for a new case.

In addition, there are relevant indicators in the records and medicine management domains that mean a single patient could count five or six times towards points in the Q&O, all captured at one appointment.

To demonstrate the potential significance of such a joined-up approach, the table uses real data from a practice in the North-West with a list-size of 12,000 patients. The number on these four registers adds up to 2,522 but the actual number of people with any of these conditions adds up to only 1,694. This is because 13 people feature on all four registers, 57 people feature on three, and 675 on two.

Moreover, the table shows 83 per cent of diabetics, 77 per cent of CHD, 87 per cent of stroke/TIA and 44 per cent of hypertension also have one or more of the other three diseases. The most frequent overlap is between CHD and hypertension (306 people) followed by diabetes and hypertension (237 people).

A nurse, or even a health care assistant, could comfortably carry out the checks required for the Q&O for all these diseases. If this practice focuses on each disease register separately it will send out 2,522 invitations for a check-up to capture the data at least once.

However, if the practice pays attention to those with multiple conditions, concentrating on those with the most first, it will send out only 1,694 invitations. Thus, the workload will be reduced by one-third.

Another aspect to consider is the audit timeframe. For hypertension the audit looks back over a nine-month period, but for the other three domains the audit time is 15 months. It makes sense for a practice to invite the diabetics and CHD patients who also have hypertension for their check-up after June when their data will count towards the hypertension domain in the Q&O.

To provide better care to patients and deliver the new contract, practices need to be more systematic in their approach. They need to develop robust disease registers, exploit the multidisciplinary team to provide check-ups in call and recall clinics, record information intelligently on the computer, take into account patients with multiple diseases, measure progress monthly, engage GPs in mopping up defaulters and shape services around the patient.

Primary care's long-term commitment to patients, its easy accessibility and its breadth of service provision, make it best placed to carry out chronic disease management across numerous diseases, especially when patients suffer from multiple conditions.

David Lyon is GP in Runcorn and adviser

to the Primary Care Collaborative

Why this topic is in the news

mLast month Health Secretary John Reid announced that

US-inspired 'proactive' management of chronic disease would be rolled out in England and Wales

mPilot sites claim to demonstrate major savings in resources and GP workload, and cuts in hospital admissions

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