Shame on you for your MMR protest
GPs need to know how much it is going to cost them to get those final points, says Dr Peter Stott
The new GP contract is as much about data collection as it is about providing quality services. Data is income; but enhanced clinical care involves cost. The Government expects GPs to be businessmen and to balance the revenue against the costs of collecting it. We are only going to collect the data if it is easy to do so and are only going to provide services if they are clinically meaningful or deliver a profit. In my practice we are evaluating our attitude to those final few points and it is interesting to review our strategy so far.
Since last December we have done a lot of work towards attaining our aspiration. EMIS has modified our software, PRIMIS has visited and produced an audit of inconsistent Read codes, and the PCT has audited us using the quality management audit system.
We have a good idea where we are going to be on National Prevalence Day, February 14, 2005. QMAS suggests that 425 of the 527 points available for clinical medicine will be 'in the bag' but we are now questioning whether the final 100 points are worth the effort. A hundred points is 100 x £75 = £7,500 or £4,500 after tax. We need to know how much is it going to cost us to get those points. We are not so puritanical that we want to get the points at all costs.
Nearly half of the points available for the clinical areas of Q&O (245 points out of 527) can be obtained from creating diagnostic registers for the 11 clinical areas, and by collecting data on smoking, medication review, BP and influenza vaccine. It is important to get this data for every patient anyway because there are another 27 for population smoking data and BP.
So our practice has created a template which we complete for every person we see. At the moment, the doctors and nurse complete it; but next year we plan to involve the receptionists. It is called template W (W money) and logs height, weight, BP, smoking and record of medication review.
Some areas are easier than others. The thyroid Q&O involves an easy yearly audit. This is managed by our health care assistants who check the computer to see who has not had their annual blood test and then call them in for review. Similarly, the epilepsy data has been collected by the practice pharmacist and linked to requests for repeat prescriptions.
Influenza vaccination is another easy source of data and usually pays for itself, but you need to achieve the thresholds if you are to obtain Q&O money as well. We plan to use this opportunity to catch poor attenders and to intensively screen them on that occasion. Spirometry, BP, bloods everything can be done at the one time.
Logging influenza vaccination just for patients with asthma, COPD, CHD, stroke, TIA and diabetes can deliver 30 points with the threshold at 85 per cent for everything except asthma (which is payable at a threshold of 70 per cent).
New diagnoses for angina, COPD, asthma, etc, also provide easy data, providing it is collected at the outset. Otherwise, things like spirometry, exercise testing and echocardiograms get forgotten. At the moment, all the doctors in the practice seem to be getting this right.
Some patients can produce lots of data on just one visit. Those with more than one condition may be relevant to two, three or even four templates on the Q&O. These are our 'platinum patients' so we have placed a lot of emphasis upon efficient recall of the condition that is most likely to deliver them the metabolic syndrome people with CHD, stroke, TIA, diabetes and hypertension which very often co-exist. These four groups can together deliver 253 points.
There are sensible thresholds at which payment begins. The work is clinically meaningful; and in all these conditions, improved control has been shown to be associated with improved outcomes. So it is worth the effort.
COPD and asthma seem to be difficult areas because, for some reason, only a minority of patients attend for a recalled regular review
45-55 per cent at most booked clinics. The work involved is also quite time-consuming and in order to get it we are finding we have to perform lots of checks opportunistically, which is not ideal.
The threshold for payment begins at 25 per cent though, which makes any increase in data relatively worthwhile. In our practice some hypertensive patients didn't attend regularly either until we cut off their medicines so they had to!
The mental health Q&O is also tricky because there is no formal definition of what constitutes a severe long-term mental health problem. Some PCTs have (belatedly) produced their own definitions but we need to ensure our numbers are similar to other practices.
One of the partners is working with the mental health team to compile a register and the health care assistants have responsibility for auditing and taking bloods for patients on lithium. Another partner is constructing a cancer registry and ensuring the review data is complete.
Patients in care homes, housebound patients and patients who are non-compliant are among the most difficult. In our area it is rare for care home staff to take blood. The district nurses are overworked, and our practice nurses are not insured to provide such care unsupervised outside the practice.
So unless the doctors see each of these patients individually and take fasting bloods at an appropriate time, our data on these patients is incomplete. I suspect many will end up exempted for some aspects of Q&O though even in this case, any data we do obtain will count towards points.
Micro-albuminuria testing for diabetes patients is another source of contention. Although we routinely test for proteinuria, only about a third of patients will bring early-morning specimens for micro-albuminuria. Micro-albuminurea testing sticks are expensive (they cost us about £2 each) and there are only three points (£225) available in total. So it is not cost-effective to provide this service. Someone should think harder about the implications of this because the detection of micro-albuminuria is undoubtedly a very important screening test to detect early nephropathy in diabetes.
The biggest problem is getting data on patients who attend hospital a real dilemma in diabetes because the local diabetes network has little effect in improving the quality of data flow from the hospital diabetic clinic. PCTs really need to get their act together on this one because, at the moment, the DGH treats upwards of 35 per cent of our diabetes patients mostly those on insulin.
Current state of play
According to QMAS, we currently can expect to obtain 427 of the 550 clinical points, with another 30 expected for flu vaccination. So there are another 103 points we could go for. A brief analysis shows they fall into the following categories:
Difficult (high cost)
·Hospital diabetes data
·Data on patients in residential homes
·Improved BP, cholesterol targets
(about 50 points)
Moderate difficulty (moderate cost)
· Exception reporting
·Spirometry for COPD
·Record of ACE inhibitor, ?-blocker use in CHD/diabetes
·Micro-albuminuria testing in diabetes
(about 15 points)
Easy (low cost)
·Mental health register (about 35 point)
So we think we will probably not try overly hard, but that we will continue to work towards another 50 clinical points, concentrating on the flu campaign. We will be satisfied with that.