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Quality and productivity QOF dilemmas

The new QP indicators have presented some tricky conundrums for practices. Dr Russell Brown provides his advice


Script data holes

You believe your primary care organisation has not provided your practice with a reasonable level of data on prescribing with which you can effectively conduct your review. How should you approach this problem?

The QOF guidance under QP indicator 1 clearly states that PCOs ‘must provide practices with data on their prescribing and comparisons with other practices in the PCO area and nationally to enable practices to review the clinical appropriateness and cost-effectiveness of their prescribing'.

A sensible first step would be to approach the local medicines management team to discuss what additional data is needed to review, and monitor changes in, its prescribing activity.

Ideally, you need the PCO to give you data from the Prescription Pricing Authority, and there's no reason why they shouldn't provide you with it. Practices can also generate data themselves, although this doesn't correspond to the actual spend on medicines. You might be issuing scripts patients never collect, in which case there's no cost to the NHS but GP time.

If your PCO has picked one area where it can get robust data, you could then compare it with your own practice-generated data. That can provide interesting results, but it could also potentially be quite laborious.

Without benchmarking data, it is impossible for the practice to engage fully with the processes in QP indicators 1-5. But if the practice follows the processes, even with inadequate data, it will be in a good position to argue compliance at year end and claim its points. While the point is to make improvements, you don't need to show you've made any – only that you've reviewed your performance.

If data is inadequate, it is likely that all the local practices will be in a similar position, in which case an approach to the LMC is likely to reap benefits for all concerned.

In the unlikely event that the PCO declines to provide any additional data, perhaps believing that the data it had provided is adequate, it would certainly be sensible to involve the LMC at an early stage. This would help the practice do the work mandated in the QOF guidance in a timely and meaningful fashion.

Referral pressure

Your practice already has a low referral rate, but you are concerned your PCO expects you to reduce referrals further to what you view as inappropriate levels in order to attain QOF points. How can you effectively argue that your practice should be permitted to maintain its current level of referrals?

Any doctor's first responsibility is to the patient sitting in front of them, but we must also protect and promote the health of other patients and the public. Part of this protective role could be argued to include responsible use of the available resources. This may involve changing the way you refer.

Some PCOs have considered a reduction in referral numbers to be desirable. While it is true that there is often much variation between GPs in referral rates, in practice it is often difficult to identify referrals that may be viewed as ‘inappropriate'. Different doctors will have different levels of expertise and varying degrees of comfort with risk and its management.

In a practice that is already a low referrer, further reductions may not be safe. Referral rates on their own are not a good measure of either cost or quality.

Under QP indicators 6 and 7, the practice must review referral patterns internally and with peer review, respectively. You could compare yourself with other referrers by benchmarking against other local practices – but doing a case-by-case review is not that helpful.

There is actually nothing in the QOF guidance that states a reduction in referrals is required to attain the indicators. QP indicator 8 involves engagement with development and following of three agreed care pathways to attempt to prevent inappropriate referrals. This process should be led by the PCT and its focus should be on long-term conditions.

It is likely that the practice in the example will not be alone in its locality in having concerns and for this reason it would be sensible for practices to ask the LMC to get involved. The LMC is in a good position to advise the practices and PCO of what is permitted under the regulations.

Many PCOs find engaging with the LMC is a good move in the long run and should allow a mutually acceptable solution. Hopefully it will result in improved patient care and, as a secondary consideration, reduced costs.

Access criticism

Your PCO judges that access to clinicians in your practice is inappropriate in light of the patterns of A&E attendance, but you have already made changes and disagree. How do you reconcile the disagreement while attaining your QOF points?

A new indicator, QP17, is introduced in April. It states: ‘The practice meets internally to review the data on A&E attendances provided by the PCO no later than 31 July 2012. The review will include consideration of whether access to clinicians is appropriate in light of the patterns of A&E attendance.'1

Most managers seem to feel GPs need to improve access to primary care, but there's no evidence it makes any difference to A&E attendance. But the QOF points will help us understand why people use A&E, and what alternative pathways we could develop to healthcare providers such as pharmacists.

As the practice has apparently already made changes to access arrangements, a useful resource might be the practice's patient participation group, with or without patient surveys.

If it is possible to show that patient satisfaction with access is acceptable or better, there is much to be said for waiting until next year and then engaging with the new QP indicators for A&E. It is possible that the peer review process in QP13 will either confirm the practice's position or suggest alternative ways the practice can improve access.

It should be noted that the phrase ‘if appropriate' is included in this indicator, implying action to improve matters may not be needed. Once again, in the event that the disagreement is insoluble, involving the LMC is likely to help all parties resolve any difficulties.

Dr Russell Brown is a GP in Eastbourne and chair of East Sussex LMC


1 BMA. Guidance on A&E indicators. 2011.