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The second of four articles looking at the new contract and its effects one year on

What does QOF data say about you?

New contract architect

Dr Tony Snell and his SHA colleagues Steven Wyatt and Bev Norton give the first detailed analysis of QOF performance data, with a focus on diabetes

Birmingham and the Black Country strategic health authority was the first to interpret and present the data provided from practices that signed up to participate in the QOF.

The overall result was good. More than 40 per cent of practices achieved more than 1,000 points and 90 per cent achieved above 750 points, suggesting most practices had worked to deliver good care and improvements in their organisation.

We also found each PCT had at least one practice achieving an extremely high score of above 1,040. However, there was also great variation between PCTs in how the QOF scores were spread out.

Some of the general overall conclusions we were able to draw are shown below. We were also able to assess in detail performance in a number of the clinical indicators. Here,we outline our findings from diabetes.

Diabetes ­ just how much

was out there?

We found the prevalence of diabetes did follow underlying patterns of deprivation and ethnicity, as expected.

However, when we compared the QOF data with rates predicted by the PHO-Brent-ScHARR diabetes population prevalence model, there was again much variation between PCTs.

Some had identified 96 per cent of patients with diabetes, others had failed to identify more than a quarter. There was also great variation between practices in the diabetes indicators achieved.

What practices can do to achieve 1,000 QOF points or more

Many practices achieved over 1,000 points, but for those that did not, what can you do? Practices will need to determine where they did not achieve points and whether this was through lack of infrastructure, lack of outside resources or lack of incentive.

The following advice, adapted from the 'Team PC' materials produced by Medicom Group for Pfizer Ltd, illustrates how diabetes indicators can be maximised.

The toolkit is available on the primary care section of the NHS clinical governance support team website: www.cgsupport.nhs.uk

The full version of this excellent support material for the QOF is designed using the experience gained from East Kent's PRICCE (Primary Care Clinical Effectiveness) programme, the precursor for the clinical component of the QOF.

Diabetes indicators

Initial practice planning checklist

·Assign responsibility to a team member for the production of disease register.

·Determine capacity required within practice to manage its patients with diabetes and the arrangements, eg dedicated diabetes clinic, opportunistic appointments.

·Decide changes needed to practice IT system. Assign someone to implement them.

·Establish training requirements of team and ensure sufficient resources available.

·Decide what links needed with secondary care and deal with shortfall.

·Use community pharmacists to help achieve indicators.

Disease registers

·Need accurate, up-to-date and active register.

·Searching on higher level code for diabetes mellitus, C10%, will pick up all coded patients on register1. Cross-reference with search on oral anti-diabetes medication, all insulins and diabetes testing strips (to pick up the diet-controlled diabetes patients).

·Also search on: fasting glucose levels, HbA1C tests, attendance at diabetes clinics in previous two years.

·The use of certain drugs may be associated with undiagnosed diabetes, eg steroids and antipsychotics. Screening may be helpful here.

·Ensure everyone is using same Read codes.

·Computer-search on Read codes or prescribed medication, or do manual search of patient notes.

·Use agreed template that prompts and displays information needed, eg structured computer template.

·Do not code anything until you know the diagnosis accurate.

·Be clear who is going to code diagnosis, and when.

·Include all patients newly diagnosed with diabetes as they are identified.

·Use appropriate administrative staff and health care assistants to help where possible.

·Run monthly or bi-monthly searches to check accuracy of register.

Teamwork and skill mix

·Consider what extra work has to be done, who can do it and when.

·Appoint diabetes co-ordinator to oversee and organise this area, define and agree responsibilities, provide training and supervision.

·Update practice guidelines, ensure every member of team signs up and adheres to it.

·Ensure that appropriate nurses have sufficient time, training and support to run diabetes clinics.

·Two key roles in diabetes care are the specialist nurse and diabetes co-ordinator.

Specialist nurse

·Helps manage growing number of people with diabetes and the complex management issues that will arise.

·Needs dedicated time. Either more practice nurses will need to be employed and/or some of their workload will need to be delegated to other team members such as health care assistants.

Diabetes co-ordinator

·Could be practice nurse or administrator.

·Responsible for making sure that every person with diabetes has all tests and clinic appointments necessary each year and persistent defaulters are highlighted.

·Community pharmacists can be used to help achieve indicators.

·Ensure practice is kept informed of local diabetes network activities.

·Have regular team meetings to discuss workload, achievements, changes in evidence base, difficult patients and communication.

Interaction with secondary care

·Many patients with diabetes have care shared between primary/secondary care.

The specialist nurse plays key co-ordinating role.

·Agreed management guidelines and clear lines of communication regarding delivery of care are needed.

·The NSF for diabetes calls for PCOs to develop integrated diabetes networks that work across traditional service boundaries2.

·Most areas will also have a diabetes local implementation team bringing together a range of stakeholders.

·The NSF highlights role of secondary care in supporting primary care in further developing services2.

·Colleagues in secondary care can provide: outreach services in the community; advice, education and training to health care professionals; help developing local protocols and refining knowledge management and quality assurance systems in primary care.

·Establish efficient mechanisms to capture patient data from secondary care to be added to practice systems. Templates agreed with secondary care useful.

·Evaluate links with other primary care services.

·Consider possibility of organising 'one-stop shop' for patients, providing a range of services in co-operation with secondary care and other stakeholders.

Medicines management

·The medicines management indicators relate to prescribing records and prescription availability. Two of the indicators refer specifically to medication reviews3.

·An effective repeat prescribing system will ensure that non-compliant patients are identified and appropriately managed.

·More aggressive treatment and an increasing number of patients with diabetes will inevitably result in increased prescribing: ·oral diabetes treatments and insulins ·testing strips ·statins ·ACE inhibitors ·antihypertensive medications.

References

1 NHS Confederation (2003). Quality and Outcomes Framework: Guidance. Available at: www.nhsconfed.webhoster.co.uk/docs/

quality_and_outcomes_framework_guidance.pdf

2 Department of Health (2001). National service framework for diabetes. Available at: www.dh.gov.uk/assetRoot/04/05/89/38/04058938.pdf

3 GPC and the NHS Confederation (2003). Investing in General Practice: The New General Medical Services Contract. Available at: www.dh.gov.uk/assetRoot/04/03/49/33/04034933.pdf

Useful websites

·National service framework for diabetes delivery strategy: www.dh.gov.uk/assetRoot/04/03/28/23/04032823.pdf

·NICE Diabetes Clinical Guidelines:

www.nice.org.uk/catcg2.asp?c=20034

·SIGN ­ Management of Diabetes:

www.sign.ac.uk/pdf/sign55.pdf

Some initial conclusions from QOF data in

Birmingham and the Black Country SHA

·Higher QOF scorers tend to be practices that have larger lists, operate in more affluent areas and are more likely to be training practices. They also tend to have better prescribing patterns and lower emergency admission rates.

·Lower QOF scorers all had small list sizes.

·Achievement in smaller practices was much more variable, with achievements ranging from less than 300 points to the 1,050 maximum.

·Hypertension, asthma and epilepsy were the disease areas that had the most extreme variation in the reported prevalence rates.

·Deprivation is not an indicator of poor quality. We mapped out the geographical area and its deprivation score and then plotted the practice scores on this map. Neighbouring practices operating in areas of similar deprivation achieved markedly different scores.

What will your PCT want to do now?

PCTs have a statutory function to improve the health of their population. Historically, PCTs have provided support and facilitation to struggling practices.

BBC SHA will be encouraging its PCTs to look at the achievement in individual practices and ascertain why, recognising the voluntary nature of the QOF, there is variation between practices in a similar location.

The emphasis will be to ensure patients receive the interventions they require. This 'gap' in care may result not only from practices not aiming to achieve the target but also from the target level for indicators being set below 100 per cent or from unacceptable exception reporting.

There is some evidence to suggest that levels of exception reporting vary considerably. Exception reporting is often necessary to achieve indicator results close to 100 per cent. However, PCTs need to be assured that the use of exception reporting is legitimate and not cynically used to boost results and deny treatments to patients.

PCTs should be seeking to support practices with lower scores to develop an action plan to attain maximum achievement in 2005/6, concentrating on areas where, clinically and organisationally, indicators were not achieved. It may be necessary for PCTs to consider commissioning services for these patients outside of the practice.

However, as the NHS requires PCTs to become 'fit for purpose' as described in the Department of Health document Creating a patient-led NHS (April 2005), they must become more robust in terms of their contract management with all their providers, including practices. PCTs may look at alternative ways of improving primary care provision for sections of their population, encouraging contestability by the use of alternative provider medical services including the private sector and by the use of practice-based commissioning.

The future

The QOF is currently being renegotiated. The success of many practices achieving near-maximum clinical points demonstrates the capacity of practices to respond to clinical targets. It is likely that the maximum percentage available for many of the indicators will be raised to a higher threshold, encouraging even better outcomes, particularly for the hard-to-reach groups, the difficult-to-manage and those that would benefit most from the evidence-based interventions.

Following the publication of the public health White Paper (2004) it is probable that smoking prevalence, BMI and ethnicity recording in the 15-75 age group will be included in QOF2 as well as changes to duplicate payments for hypertension etc. Changes are likely also to align NICE and NSFs (eg renal).

As points are worth significantly more this year it makes sense to maximise scores and prepare for next year. The Kent experience of PRICCE showed that as time went on the need for and the number of actual exception reports dropped dramatically. PRICCE also showed that practices had to respond to the challenge of sustainability by making the changes described (see left) to avoid burnout and reduced outcome results.

PCTs will be looking ever more carefully at exception reporting and prevalence rates to satisfy their auditors.

An in-depth look at three of the diabetes markers

Retinal screening

Indicator DM8 The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months.

What data revealed The chart examines the nature and extent of variation in results for DM8. Practices are represented by dots, with the position of the dot against the vertical axis indicating the practice score for DM8.

Practices are ordered from left to right in order of the size of their diabetes disease registers. The red funnel indicates the upper and lower control lines. The extent of variation outside these control lines highlights the lack of process control in retinal screening access for diabetics. Attempts will be made to understand and reduce this variation in BBC SHA.

What you can do

It is a PCT responsibility to commission evidence-based retinal screening and a Department of Health timetable shows when it must be done by.

Meanwhile, GPs must refer all patients on their register for screening according to local and national protocols. The practice cannot be penalised if it has a long wait but the PCT must meet its outpatient waiting time targets. More importantly, some patients may have their visual acuity saved.

Controlling HbA1C

Indicator DM6 The percentage of patients with diabetes in whom the last HbA1C is 7.4 or less (or equivalent test/reference range depending on local laboratory) in last 15 months.

What data revealed Average practice performance is close to 57 per cent and the vast majority of practices achieved above 25 per cent. Again there is big variation between PCTs. In one PCT more than 50 per cent of practices fell into the lower quartile while in another PCT close to 50 per cent of practices fell into the upper quartile. Approximately 30 per cent of practices fall outside control limits.

What you can do Encouraging and managing glycaemia control can best be achieved through patient concordance. One way of achieving this is the proven route of the 'expert patient' programme. Providing education and support to diabetics and their families is part of this process. It can be done at a practice or PCT level. Dietary and diabetes specialist nurse expertise is critical for success. More use of metformin is inevitable, and switching to insulin more likely earlier. More frequent follow-up also has been shown to encourage concordance initially.

Are patients managed in secondary care achieving the sort of results QOF requires? If not ask the PCT medical director and commissioner to tackle the trust about why not. Have you found all the 'missing' diabetics, that haven't been diagnosed yet ­ you can ask the PCT to tell you what your expected prevalence should be for your demography, deprivation and ethnicity, etc. If there is a gap, screen these populations. Not only will this increase your prevalence factor but will tend to lower your overall HbA1C levels.

Microalbuminuria testing

Indicator DM13 The percentage of patients with diabetes who have a record of microalbuminuria testing in the previous 15 months (exception reporting for patients with proteinuria).

What data revealed This is an indicator of which patients are likely to develop renal failure unless treated properly. Average practice performance is close to 65 per cent and the vast majority of practices achieved above 25 per cent. Similar proportions of practices within PCTs fall into the upper quartile. No practices in one PCT fall in the lower quartile. Approximately 70 per cent of practices fall outside control limits. Before the introduction of the QOF, this investigation and management was very variable. There has been an improvement but much more needs to be done to prevent renal failure developing in these patients.

What you can do Microalbuminuria screening and treatment is not difficult. Ask your PCT for its protocol. Ensure the PCT has a contract for the test, or ask it what the alternative is, if necessary through your LMC and PEC.

Search all your diabetics who have not had the test, remove from the list all those who have albuminuria or who are already on a maximum tolerated dose of an ACE or A2A and then call and recall them using your nurse and receptionist. Produce a local protocol for the practice, simple written instructions for the patients, and link repeat prescriptions demands to those who don't attend.

Tony Snell is medical director for Birmingham and Black Country strategic health authority and a GP retainee

­ he was co-vice chair of the NHS Confederation's GMS negotiating team

Steven Wyatt is a senior public health information specialist

Bev Norton is associate director of the West Midlands deanery and programme director for primary care development at BCC SHA

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