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Keep ahead of the QOF game

With the targets for the quality and outcomes framework getting tougher, GPs will need to stay on their toes if they want to maintain their high points scores, says Dr John Couch

With the targets for the quality and outcomes framework getting tougher, GPs will need to stay on their toes if they want to maintain their high points scores, says Dr John Couch

This year's payment from the quality and outcomes (QOF) framework will account for around one-third of our income, or around £43,000 per full-time GP, assuming maximum points. Last year's figures show that for 2005/6 most practices will achieve more than 1,000 points out of the maximum 1,050. But from April 2006 or 2007 we will be facing tougher targets.

Many in the Department of Health and NHS Confederation feel the initial QOF targets were too easy. They have succeeded in redistributing 166 points while clamping the value of each point at £124.60 for the average practice. Some 28 of these points will be for doing more work in existing QOF areas, while 138 are for new domains.As we know, our impressive scores were actually the result of hard work by excellent practice teams. We now have to decide whether to wait for further details of the more demanding 'mark 2' QOF to come out (they are promised at the end of the month) or to move our performance further forward in anticipation of the tougher days to come.The latter approach should spread the workload, as well as increasing the chance of maintaining high scores. In pursuing this approach, you need to consider several areas.

By now, regular monitoring should be a fixed feature of your QOF management. It will help not only to highlight weaker areas, but also to spot falling trends in areas where performance may be waning. The absolute minimum requirement should be a detailed monthly review of the latest QMAS and native GP software searches. This review should be coupled with mechanisms for action in any areas of underperformance.

Continue to focus on QOF domains and indicators that do not currently produce full points. In 2004/5, it was natural to focus resources on those areas that would produce the best results. Inevitably, this meant that more difficult areas such as HbA1c levels and diabetic eye checks were put on the back burner. There is no excuse for this in 2005/6 and in subsequent years.

By now, protocols, clinics and data gathering should have become much more efficient. If there are any Cinderella areas left, try to improve these as soon as possible.You should also look at areas where we only just reach the target level. For instance, if 71 per cent of smokers with coronary heart disease have been advised to stop smoking in the last 15 months ­ the target is 70 per cent ­ we should try to increase this figure further. This approach will prevent a last-minute fall if you rushed to get figures up in the last few months of 2004/5.

Instead of waiting for targets to be increased in current indicators, it is important, from both clinical and business standpoints, to move performance upwards. It seems clear ­ and this was a relief ­ that when the BMA negotiated the target levels it argued, successfully, for lower targets in more difficult areas.

If you scan through target levels in each domain, these low-target difficult areas are relatively easy to spot. Good examples are the HbA1c (DM6 top target 50 per cent) and blood pressure (DM12 top target 55 per cent) targets in diabetes.We now know that the top target level in some or all of these indicators will be raised, although we do not yet know the details. So we should be continuously trying to improve whatever level we have currently reached. List the indicators where you feel this is likely to happen, and develop a strategy for recall, treatment and more intensive monitoring.

For the same reasons as above, the actual clinical indicators in some areas are likely to get tougher. Already the medical press has speculated over the targets for HbA1c of less than 7.5 and for hypertension of 150/90mmHg.

If you break down the spread of patients below the target thresholds, you usually find a direct relationship between numbers of patients and proximity to the threshold level. For example, a large cluster of hypertensive patients have blood pressures between 145/85mmHg and 150/90mmHg.These thresholds seem likely to be reduced, so it makes sense to pre-empt this well in advance. You should target patients with borderline readings and consider making therapeutic changes rather than accepting their current clinical status. For instance, you may decide to reduce blood pressure targets to 145/85mmHg in hypertension and HbA1c to 7.0 in diabetics. A 6.5 HbA1c target has already been rumoured. God help us if this is the case.

We now know that there will be new clinical domains in depression (33 points), atrial fibrillation (30), chronic kidney disease (27), dementia (20), mental health (nine), palliative care (six), and for setting up registers for obesity and learning disability (12).

At the very least we should all be increasing and improving our data gathering so we can produce accurate disease registers for these new areas. To be in this position we need systematic and accurate coding, so this is the first item to address. Make sure the whole team is using agreed Read codes for past as well as for new diagnoses. Review old diagnoses to ensure they are accurate. Predicting all the indicators that may be included in new domains is difficult. We should all be checking height, weight and body mass index ­ these will give a current indication of obesity. But we should also consider recording waist and hip measurements, as these seem to better predict cardiovascular disease. Check that your GP software allows these readings to be coded. Including smoking status, cholesterol and blood pressure in obese patients also makes sense.Watch the press carefully to ensure that you react as soon as more news becomes available.

With average patient turnover of about 5 per cent nationally, it does not take long for accurate data to be spoiled by poor data for new patients. Prioritise summarising new patient records and new patient checks. Be particularly careful with diagnoses such as asthma. Ensure the patient really did have asthma and enter the correct date of onset, not the current date.

With written notes we have the opportunity to correct errors and omissions when new patients join. Once records are transferred electronically, this will become more difficult. We must all try to improve our computer records now rather than later.

In most cases, establishing clinics for disease areas has been successful. We need to review current clinics to ensure they are efficiently run, and consider establishing new ones for areas not already covered, such as epilepsy and strokes.

Using clinics generally improves performance but also makes GP space for any new domains ­ although ultimately these, too, may be best dealt with under a clinic framework. Resources are a big issue.

Although the 30 quality practice points are being dropped along with 80 holistic care points and the 50 for access, non-clinical domains still make up a sizeable chunk of QOF. So do not neglect them. Apply the action discussed above.

Whatever the future holds, we are more likely to maintain high points scores by constant vigilance and reaction ­ activities in which GPs have always excelled.

John Couch is a GP in Ashford, Middlesex

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