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Tough fraud check by QOF assessors

PCT quality framework assessors are to pore over blood pressure readings, exception codes and data entered by GPs on weekends as part of tougher fraud checks.

Guidance for assessors on scrutinising this year's QOF data instructs them to look out for 'excessive' numbers of data entries on single days and 'clustered' entries around payment thresholds, particularly 150/90 BP scores. It even tells them to examine which sphygmoman-ometer GPs use.

The depth of the investigations, revealed in a 'practical guide' from NHS Employers and Primary Care Contracting, has shocked GPs. They said the process undermined the principle of 'high trust' monitoring.

Other checks recommended for assessors included looking for sudden rises in points scores particularly in February and March. Significant outliers and clinical domains with 'unusually high or low' prevalence were highlighted as potential indicators of fraud.

QOF assessors have also been told to question high use of exception reporting, particularly informed dissent, notably in asthma or diabetes.

The guide advocated questioning GPs about vague diagnoses such as 'high blood pressure'. It also instructed assess- ors to check for 'very old' blood pressure readings and 'excess' numbers of blank entries in reports. Such findings will 'give an indication of gaps in clinical care', it said.

GPs were confident they could answer assessors' questions, but queried the rationale behind the checks. They said, for instance, it was common practice for data to be entered in batches or on weekends and for more entries to be made in the final two months of the year.

Dr Laurence Buckman, GPC deputy chair, said PCTs should not challenge GPs' long-term care. 'It's not a police investigation. Generally, high trust is in place but PCTs shouldn't be able to question some of these things.'

Dr Robert Morley, joint executive secretary of Birmingham LMCs, said checks on missing or old data were 'totally inappropriate' and made visits more like clinical governance.

Dr Adrian Jacobs, lead negotiator for NHS Employers on the quality framework, said it was reasonable for QOF assessors' work to go beyond simply checking entries were accurate.

'A visit is an opportunity to have a wide discussion about clinical care. I don't believe this compromises 'light touch'.'

What they will be looking for

  • Sudden increases in achievement
  • 'Clustering' of BP readings around thresholds
  • 'Excessive' data entry on one day, especiallyweekends
  • Vague criteria for diagnosis
  • 'Very old' last entries for BP
  • 'Excess' number of missing data entries
  • 'Unusually high or low' prevalence
  • 'High' levels of exception reports
  • Which sphygmo you use

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