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Surviving year 2 without burning out
Some GPs have had to throw everything at the QOF in year 1 'including the kitchen sink', says Dr John Heather. He advises how to sustain those changes and remain sane
By the time you read this we will be
a quarter of the way through the second QOF year.
This quality agenda is a marathon not a sprint but
many practices did well last year by working so hard that they would find it difficult (and to be frank undesirable) to repeat such a performance again this year. You can work your socks off in the short term but not year in year out.
Practices in East Kent area have already experienced this dilemma. The PRICCE (Primary Care Clinical Effectiveness) project was the quality initiative that much of the QOF was based on. We learned some important lessons to pass on as we look at year two of QOF and beyond.
The wall of pain
Every practice in year one of the PRICCE programme achieved the demanding outcomes required by the project. For most this was in the same way that many practices have delivered QOF by hard work and sheer determination. However, by 18 months most of these practices (my own included) had hit a 'wall of pain' where they realised that they were neither able nor willing to continue working in the same way.
At this point a few practices continued to struggle on while most made significant wholesale changes to the way they delivered consistent quality care to their patients. These changes became known as the quantum leap and were responsible for the ongoing success of the project. Interestingly PRICCE assessors, while concerned with the detail of issues like exception reporting etc, were even keener to find evidence of these strategic changes in working practices.
The quantum leap
This is essentially a series of changes that mean quality stops being an 'add on' and becomes the 'core business'. It is about GPs not working harder (that is both unsustainable and undesirable) but practices working differently and smarter.
While there were clearly differences in approach between the practices in East Kent, in the end there were four defining features of practices that had made this quantum leap:
1) clear leadership
2) commitment to IT
4) willingness to learn and change.
Leadership is vital for delivering successful consistent quality care. This leadership needs to be there at both a clinical and administrative level.
From a GP perspective there needs to be demonstrated enthusiasm, direction and a willingness for someone to 'bottom line' the project.
Administrative leadership is vital to the extent that most East Kent practices had a designated PRICCE co-ordinator who managed the project, overseeing the process of systematic care.They were responsible for:
· making sure the right people were doing the right things at the right time
· constantly monitoring and auditing the disease registers and achievement to date
· planning and communicating with the whole team so that everyone was aware of what had been achieved and what still needed to happen and how this would be accomplished.
This role certainly does not need to be a clinician and is usually not full time, but whoever takes it on needs appropriate dedicated time and the consistent support of the GPs and practice manager.
Commitment to IT
One of the successes of the new contract has been the excellent response from most of the medical software companies to develop audit tools to help practices deliver the QOF.
However these tools are only as good as the input from staff and are only useful when used. I have been amazed to find practices who do not know how to use their in-system software. If that is you then please find a local practice to teach you it will either save you many hours or make you thousands of pounds richer.
A clean (accurate and up-to-date) database is essential for managing chronic disease. This requires practices to be diligent in their data entry and clear about which Read codes to use and when. This in turn requires both supervision and a commitment to training staff both features of practices that have achieved the quantum leap.
The QOF should not be about GPs working harder but about practices working differently. The new GMS contract was not a new GP contract but the more radical concept of a practice-based contract and rightly so because the shift to an emphasis on quality requires a shift from the GP to the practice team.
The majority of the chronic disease management required in the QOF can be protocol led and as such lends itself to being delivered better by people other than GPs, for example predominantly by appropriately trained (and remunerated) practice nurses supported by an army of health care assistants.
Reading the press, much of the criticism of the QOF has come from GPs who resent protocols, templates and 'tick box' medicine. Personally I wonder why they remain involved at that level. I agree their talents (not to mention their cost) lie elsewhere. Where practices have made this quantum leap a GP should only be doing what others in the practice cannot do.
One of the weaknesses of the new contract has been premises reimbursement and that can be an issue here. Many practices in East Kent now have new premises and this building was stimulated by the lack of space needed to accommodate the increased administration staff, practice nurses and health care assistants required to deliver consistent systematic quality care.
A willingness to learn and change
Despite its name a quantum leap is rarely achieved all at once. Instead it requires a commitment to flexibility and a willingness to learn and change. My own practice has been doing the 'QOF thing' for over seven years and we are still learning and changing. Fresh challenges bring the need for new and different solutions
Certainly every practice should by now have made time for a debrief with all the staff involved in delivering QOF to find out:
a) What went right last year?
b) What went wrong and why?
c) Is anyone else either locally or nationally doing things better or more easily? If so can you adapt to incorporate their best/better practice?
And then you need to develop a clear action plan based on the meeting which is understood by everyone involved.
Certainly now is the time when there is much in the GP press about the successes and failures of last year. It is a key time to read, learn and maybe change so that your practice will be able to sustain your performance without anyone burning out. If you haven't made it yet, I invite you to take the quantum leap.
How we made the quantum leap on hypertension
Northdown Practice profile
7 GPs (6 WTE)
1 Nurse practitioner
2 Practice nurses
2 Health care assistants
The wall of pain
This is what our workload for hypertension involved in the year 2003/4
· 1457 patients needing 2 visits per year (if well controlled as per British Hypertension Society guidelines) = 2,914 visits
· Assume 15% (218) are poorly controlled requiring 4 additional visits to bring to target = 876 visits
· Disease register grew by 29 in year - assume each needed 5 visits to achieve control ( 3 visits to make diagnosis then 2 further to achieve control) = 145 visits
· To achieve QOF meant:
- 3,935 patient contacts
- 2,170 (1,457 + (218 x3) + (29x2)) blood tests
- 1,486 (1,457 + 29) dipstick tests on urine
So the workload for hypertension in the QOF is significant for any practice.
In addition we also had three other factors to contend with:
1 Our lead PRICCE nurse retired in April 2004 and it took us some time to find a replacement meaning we were rather slow off the blocks with the QOF
This demonstrates how vulnerable practices are in the world of new GMS to changes in nursing/health care assistant personnel
2 We were changing from reporting on BP recorded in past 12 months under PRICCE to within past nine months under QOF
Under PRICCE the BP needed to be controlled to target within the year (surely more representative of real life general practice) whereas QOF took the last reading only (beware those patients seen in A&E or outpatients with a BP recorded are they ever normal?)
3 Our register was still dirty, despite our having worked hard over the previous six years at having a robust register. Fortunately with the arrival of Population Manager from EMIS we were able to track these rogue Read code entries on patients and correct them
It became clear at about month eight or nine that although we had a protocol for the care of hypertensive patients and were using a team approach to spread the workload we were not going to achieve maximum points because people, especially the nurses and health care assistants, were not being aggressive enough in managing patients eg a BP of 150/91 fails even though it is only just above the target threshold and there needs to be decisive action.
Having recognised our failings and discussed the situation at a practice meeting we were able to meet with all the staff and instil a greater awareness of the need to be more proactive in managing these patients.
The result was a substantial improvement over the remaining three months with the practice easily achieving maximum points.
John Heather was chair of the PRICCE steering group. He is now a GP in Weston-super-Mare, Somerset