Why we are in favour of male circumcision
We are into the last couple of months for maximising achievement under the new GMS quality framework and a final push for points is still worthwhile, says Dr Chris Martin
In the run up to March and the financial year-end you may find you have not quite reached your aspiration points.
There is not enough time left to hammer down blood pressures and cholesterols and have the results ready for the end-of-year audits. But there are certain things well worth doing still. How can you target the work to get the maximum 'bang per buck'?
The quality point structure was designed to reward two things. First, the work needed to achieve a target. Second, the perceived importance of that target to health outcomes. In the latter case, a target might attract a large number of points even if the work involved is light.
You need to identify these quality indicators. It is also likely that the estimates of workload were adrift in some areas, resulting in a lot of work needed for little reward for some indicators, or easily achieved points in others.
When you are looking to see what areas to concentrate on, you need to take four things into account: the number of points per indicator, the number you already achieve, the number of patients involved in achieving those extra points and the difficulty in meeting the target.
Microsoft Excel is now virtually ubiquitous in the NHS and you almost certainly have access to it. If you know how, you can use it to work out your potential 'points per person'.
If you do not know how, it is time you learnt as it might increase your income. Your local postgraduate tutor should be able to direct you towards suitable training.
So what at this late stage will give you the best improvement in points score and monetary gain for the least effort? We list the quick wins below.
Potential quick wins
At present the 'new' diagnoses for asthma, COPD, MI, CHD, LVF, stroke and cancer are likely to be low in number, but between them they account for 41 points. The effort involved per patient is often minimal and the result in terms of points gained certain, such as making a referral to a cardiologist, or measuring a peak flow. They will also continue to count towards subsequent years' quality points. Identify your new diagnoses and sort them out, but remember that for cancer reviews they only contribute to the quality indicator if this is done within six months of the diagnosis being confirmed.
For new patients diagnosed with ischaemic heart disease since April 1, 2003, refer them to a cardiologist or for an exercise stress test if this has not already happened and enter the code 8H44. with the date of referral. You do not need to wait for the result. Do the same for new diagnoses of left ventricular failure and echocardiography (code 8HQ7.) and stroke referral for scanning (code 8HQ3. for referring for MRI and 8HQ4. for CAT scanning). Again, you do not need to wait for the results.
Asthma is probably the most productive area to concentrate on. There are 15 points on offer, and the numbers will not be large. The prevalence of asthma is high, but the incidence of new diagnoses is not that great. This is because it is often diagnosed in childhood, and asthmatics tend to have a normal lifespan, unlike patients suffering from coronary heart disease or stroke. Identify all the new diagnoses since April 1, 2003, and check the records. You may well find a number of them have had a peak flow since diagnosis, but that it has not been recorded on the computer. For those that remain unchecked, bring them in it is almost certainly worth it.
There are 30 points on offer for advising smokers on quitting. This is probably not as arduous a task as it might seem, as the prevalence of smoking in those with diabetes, asthma, COPD, CHD and stroke is relatively low and it is easy to do. Identify all the smokers who have not been advised and then ring them up if the number is manageable.
If not, write to them enclosing a leaflet giving advice on stopping with the number of the smoking cessation clinic and an offer of assistance with nicotine replacement if appropriate. Enter the code 8CAL. into their records.
Patients with multiple diagnoses have a higher 'points per patient' score as they crop up repeatedly in different quality indicators. A smoking, hypertensive, diabetic with ischaemic heart disease scores three times the usual 'points per patient'. Any patients with multiple diagnoses including CHD, stroke, COPD/asthma or diabetes will have at least double the points per person for influenza vaccination. Even if it is too late for this season, they would be important to target next year.
Identify your patients with ischaemic heart disease, stroke or diabetes who have not had a cholesterol check in the past year. As repeat prescription requests come in put a completed blood form and covering letter in with the prescription, or post it to them if you prefer. Suppose it costs 60-70p per letter sent, and two-thirds of those who are sent a letter have the blood test, this equates to a cost of about £1 per cholesterol measured.
It is important to consider the cost-effectiveness of such an exercise as there may be a risk of spending more in the mailshot than will be earned in extra points.
To assess the risk we need to take a worst-case scenario and see if that is still in profit.
If you are a GP with 75 ischaemic heart disease patients, none of whom have had a cholesterol test in the past year, you could expect to gain four points if they are all sent a form and an invite for a blood test and if two-thirds actually have it done. These four points would be worth about £100 to an average GP with a list of 1,900 patients. And they will only have cost £50 to do.
However, it is likely to be much more profitable than this as many of the patients will have had a cholesterol check already, the uptake is likely to be more than 60 per cent and some of those with ischaemic heart disease will also be diabetic and contribute to another quality indicator.
Patients on lithium
Finally....If you don't know already, and you surely should, gaining points for checking the levels in patients taking lithium is like falling off a log. An average GP will have one patient on lithium, and will gain at least three points for checking that
one level. That GP will
gain five more if it is within the therapeutic range. Just do it!
Chris Martin is a GP in Laindon, Essex
Things to consider when deciding which target area to concentrate on
·Number of points per indicator
·Number of points you already achieve
·Number of patients involved in achieving those extra points
·The difficulty in meeting the target