1 Service-level agreements (SLA)
Name Sheinaz Stansfield
Potential income per patient Up to £100 a year, plus a £1500 starter payment per home
We found a lot of hospital attendances coming from nursing homes in our area and that patients were receiving a poor level of care that wasn´t planned very well. So we set up a service level agreement with Gateshead CCG - similar to how a LES worked with a PCT - and gave practices the option of signing up to it.
Basically practices have the option of taking charge of care for nursing homes - however many they feel they can handle. My practice started off with four. We now have eight. Practices receive an initial payment of £1,500 per home. They undertake quarterly reviews and receive £25 per patient per review or £100 per patient per year. If there is evidence at the end of the year of a fall in A and E attendances and admissions, they receive an extra £500.
- In my practice we are breaking even on this. The SLA stipulates a ward round by a GP of one hour per week but our GPs do more than that as they want to go the extra mile in terms of patient care and improving patients´quality of life. But where we´ll really make practice income by reducing admissions is in the longer term, through larger list sizes and through QOF. The savings have enabled us to pay for two whole-time equivalent nurses specialising in older patients which will further dividends in terms of further reducing admissions.
2 Risk profiling and care management DES
Name Dr Seth Rankin
Location Wandsworth Medical Centre, south London
Potential income per patient 74p
The five specifications of the DES are to:
- Carry out an at-least quarterly risk profiling exercise of registered patients using a risk profiling tool or commissioning support service;
- Agree the definition of ‘active case management’ with your CCG
- Assess the list with a multi-disciplinary team to find out who needs active case management
- Meet the MDT at least quarterly to improve quality of care and reduce individual risk of emergency admission
- Nominate a lead professional to undertake a review and care-planning discussion at a frequency agreed with the patient.
I work in Wandsworth CCG and we got a head start on the DES by designing a comprehensive LES which incorporates risk stratification to identify our most vulnerable patients and incentivises GPs to deliver the RCGP care planning model.
Practices can earn approximately £120 per patient to use our risk stratification tool, supplied by SOLLIS Clarity, to identify patients then give them an hour-long appointment that focuses on their health needs, expectations and promote self management. The business case for this is to reduce unplanned secondary care utilisation where safe and appropriate to do so.
To undertake the LES, a practice trains at least one GP and another member of staff to use SOLLIS Clarity, identifies at-risk patients (multiple long-term conditions, at risk of falls, end of life Care, dementia, housebound, carers) and asks them to prepare questions and issues they want to discuss with their GP before coming in for a 45-60 minute appointment.
We’re not ‘double-paying’ GPs but the LES offers resources for GPs willing to go beyond the DES specifications.
- Some practices will already be doing much of this work – some may already have a LES in place. In that case, rationalise your work and resources – but, as has been said before, don’t do the work twice. Check where it overlaps. In Wandsworth we were lucky to have funding available through the Better Services Better Value scheme, so we designed a comprehensive LES that enabled GPs to identify and then treat all their most vulnerable patients in a consistent and easily monitored way. We provided a system to delver a proven model (the RCGP care planning model) to enable GPs to provide a service that was not already being paid for under their GMS or PMS contracts.
- If you haven’t already got a LES available through your CCG, pitch one. Use the DES as a foundation to enable GPs to identify vulnerable patients but expand it (via a LES) to delivering longer, more patient focused consultations. Explore local funding options for admission reduction projects and QIPP. Design something that co-opts commissioner and GP aims to better treat patients and reduce secondary care costs.
- Practices with smaller populations of ‘at risk’ patients (such as inner-city or university practices) may find this DES to be ‘low-hanging fruit’.
3 Clinical indicators in the QOF
Name Dr Pablo Millares Martin
Potential income per patient Variable
The elder population is growing slowly in our practice, as it is everywhere. You can not keep increasing appointments to deal with their increase so the only way forwards is to prevent events, to manage patients early in their disease so you can modify the pathway they are heading into (ideally one with little number of complications).
By assessing/reviewing your elderly population fully rather than limiting to the presenting complain they come with, you should be able to ascertain potential diagnosis (hypertension, diabetes) and reducing the impact of possible complications (Stroke, TIA, heart disease). By detecting disease early, by increasing the prevalence of QOF conditions but without the hospital intervention due to complications it is likely they are going to be patients easier to treat, easier to score positively on the outcome framework.
When assessing hospital admissions, there a few things to consider. On one hand is access to primary care, as the worst it is the most likely patients will attend to emergency services to deal with their needs.
On the other hand is general management of chronic conditions, as the better controlled the less likely of flare-ups (like asthma and COPD exacerbations, and angina attacks).
Good management of the QOF generally reflects good management of chronic diseases too. So, a practice with adequate access systems and in good order with their QOF achievement can be presumed to be less likely to get patients admitted. A combination of less exacerbations, better health education and understanding of their conditions, mor self management and in consequence less demand on physicians.
The following indicators (QOF 2013/4) might improve chronic disease management at your practice:
- Rheumatoid arthritis indicators that require a risk calculation of cardiovascular disease and osteoporotic fracture (RA003/004). I have been surpriseddoing the QRISK2 in a patient last week and finding out his risk was over 40% despite normal pressure and not current smoking. I did not even realised he has been diagnosed with rheumatoid in 1994, as never complained of it, but the alerts I put on the diagnosis did the trick….and now he is on statin hoping not to have a stroke/other in the future.
- Reducing unscheduled admissions through patient education, diabetes (DM014). The use of educational program has been our standard for the last two to three years. Unless the patient fully takes responsibility of the fact the diabetes type 2 is a direct consequence of a long term unhealthy lifestyle, you are fighting against a wall. It is paramount to educate them, to stop the typical lies pretending they are following a diet they are not, and unfortunately the short consultations in primary care are not enough to cement these concepts.
- Calculating CVD risk (PP001). There is large population in need who does not know they are at risk. Many years ago we hade the rule of halves in hypertension, were half of the patients with it did not know of the diagnosis, and of those treated half were poorly controlled. It is now in the past, thanks to the QOF.
The next level is to deal with the cardiovascular risk secondary to smoking and cholesterol, where is likely to be a considerable amount of people unaware of the considerable risks they are under. A consultant cardiologist was recently stating in a meeting I attended he was thinking about statin for himself, as there is a tendency among many of them to favour the idea everybody should be on aspirin or statins once you reached certain age. Probably a bit drastic, as no medicine is without side effects, but by targeting those patients with higher risk factors, the incidence of heart attacks and strokes will no doubt diminish.
- Lower blood pressure target (HYP003). Arguably this aggressive target might in fact increase admissions. One has to put the patient first, and accept lower blood pressure is better, but exception reporting is there to avoid medicating patients who are at higher risk by aggressive hypertensive treatment
Some might say income from QOF points is too volatile to resource reducing admissions and you cannot be certain you are going to achieve your aspirations, mainly when the Government agenda is to reduce payments to practices, which leads to poorer access and higher rates of hospital admissions.
What can be argued on the other hand, is that well controlled chronic disease should prevent exacerbations and admissions.
- Offer an annual review for elderly patients. The population at our practice is younger than average. Leeds itself is a young city (14.2% of the population is over 65 versus a national average of 16.3%). That reflects in the fact we are only dealing with a small number of residential patients, and the approach has been to do one visit a year to assess their needs on top of the ad hoc acute requirements. It allows us to focus on the management of chronic disease and to get all the QOF points for that patient in one go.
- Don’t think QOF is just for the second half of the year.Indicators started to count on 2 April. I have already done several rheumatoid check-ups (with some surprises as mentioned above).
- Don’t rush into therapeutical decisions about blood pressure checks. You need to monitor and asses the response with enough time to allow a gradual change, avoiding A&E visits with hypotensive episodes.
4 QP indicators in the QOF
Name Dr Chaand Nagpaul
Location Stanmore, Middlesex
Potential income per patient 79 QOF points for indicators QP5-9
We undertook all three QP indicators on emergency admissions last year. This was assisted by our local shadow CCG, Harrow, who had also offered additional funding via a Local Enhanced Service that supplemented the QP requirements, so that we were resourced to be part of a peer group with monthly meetings, as well as participating its integrated care pilot. This follows a LES designed by the old PCT for the area.
As part of the old QP9, (‘The practice meets internally to review the data on emergency admissions provided by the PCO’), each of the six GPs at my practice case-reviewed a sample of emergency admissions, which was then followed by a practice meeting in which we had a group feedback and discussion on learning points. These took about one or two hours for each GP, and we had a two-and-a-half-hour meeting.
Then one GP from the practice attended a local peer review meeting (as per QP10; this took around three hours), as well as attending on-going peer groups as part of the LES.
Lastly, as part of the old QP11 (‘The practice engages with the development of and follows three agreed care pathways’) we developed and followed pathways for managing patients at home via a community rehabilitation team (e.g. for suspected DVTs), and case managing high-risk groups (vulnerable elderly patients, and diabetic patients). This was developed by the shadow CCG with dialogue with the peer group; ‘development’ therefore did not take the practice time, but the bulk of the work has been in implementing and adhering to the pathways. It is difficult to quantify how long this took - each GP had to familiarise themselves with the pathways and clearly there was added effort and time in adhering to the pathway in terms of, for instance, using pro forma to refer, and liaising with rehab team.
Practices will need to do their own calculations on the amount of time it will take to undertake each of the tasks (meetings and report-writing, and implementing a plan to reduce admissions). They will need to justify what they’re able to prioritise in context of a significantly increased workload via the imposed contract changes in 2013/14.
- For 2013/14, practices should be familiar with the specific QP indicators and wording, some of which has changed, and restrict their workload to these requirements. The QP indicators require an internal practice review of emergency admissions with a single peer review meeting. There is now no need for an end of year report. Any further on-going referral analysis and peer review meetings are not funded from the QP indicators, and practices should not agree to any such additional work without supplementary funding via a local enhanced service. The QP indicators also offer opportunity for practices to suggest commissioning or service redesign changes- this is important since many strategies to reduce emergency admissions will be beyond the practice’s individual control.
- Many CCGs have therefore been helpful in trying to build on these indicators, via a related local enhanced service, which can provide additional resources. My local CCG Harrow has developed a local enhanced service to supplement the QP requirements with on-going reflective work on reviewing emergency admissions and following pathways, both via regular peer group meetings, but also via a peer assessment programme. There is additionally an integrated care pilot to provide funding for risk profiling of patients at high risk of admissions, and case management. It might be an idea for practices to request your local CCG, with assistance from the LMC, to help resource these QP indicators with a supplementary LES which would expand the income stream for this work.