The new GP contract – quality and governance issues Susan Neal Nurse-practitioner

This session Quality & new GMS Contract Quality Chronic Disease Management Some Issues Examples from practice

Rewards for Quality £1.3bn for the UK for quality in GMS & PMS No quality pool Non-discretionary In addition to the global sum Payment for what many already do All work converts to points 1000 maximum points –Value £75 in 2004/5, £120 in 2005/6 for average weighted population

Aspiration & Achievement Money in advance for equipment and staff Aspiration payment –In advance monthly –Rising as you aspire higher and = 1/3 total Reward dependent on level of achievement Over-achievement paid in full

The four domains of quality Clinical Organisational Patient experience Additional services and linkage payments Holistic care - clinical Quality practice - organisational 50 bonus points for access target achievement –additional to the Q&O Framework

Balance of 1000 Points Clinical 550 Organisational 184 Additional services 36 Patient experience 100 Holistic care 100 Quality practice 30

Clinical Areas CHD and LVD Hypertension DM Stroke or TIA Hypothyroidism Epilepsy Asthma COPD Mental health Cancer

Organisational Areas Records and information Communicating with patients Education and training Clinical and practice management Medicines management

Breadth v Depth Holistic care payments across clinical domain performance in 3 rd lowest area Quality practice payments across other three domains

Principles Evidence-based Indicators fair Clinical indicators are measurable Not disruptive to consultation

CHD - the biggest marker set points register patients with newly diagnosed angina who are referred patients with record of smoking patients who have been offered smoking cessation advice patients with record of BP patients with BP < 150/90 patients with record of cholesterol patients with total cholesterol < 5 patients on anti-platelet therapy or anti-coagulant patients on beta blocker patients on ACE inhibitor patients with influenza immunisation

Exception Reporting – you don’t have to count them if… Patients refuse to attend three times New patients or recently diagnosed It is not clinically appropriate They have given informed dissent They cannot tolerate medication / therapy They are taking the maximum medication They have another supervening condition Secondary care service not available

High Trust Reporting Data entry as you see patients Audit data generated by normal workload Annual report on computer Almost no claim forms to fill in Very little paperwork Visit from PCO to verify annual report Appeals if you think PCO is unfair

Quality: Preparation & Delivery Preparation payments 2003/6 - £3000 per ave. GP Count data for all the markers you can Decide where you are Decide how high you wish to aspire Discuss this with PCO Receive aspiration payment monthly Do the work Receive achievement payment at standards achieved

Quality points : hypertension INDICATOR register of patients smoking status smoking advice BP recorded in last 9 months BP < or = 150/90 COVERAGE POINTS yes/no % % % 56

Smoking status - BP2 No on register = 100 Smoking status recorded = 70 Exception reported = 10 No on register after exceptions = 90 Achievement = 70/90 = 77.78%

Smoking status - Achievement Points for 90% threshold = 10 There is also a minimum achievement threshold of 25% Practice points achieved = ( )/(90-25) x 10 = x 10 Therefore achievement = 8.12 points

Information Management & Technology Vital Existing systems can cope Guidance on Read codes

Key Elements in quality CDM Systems for those with current and future disease Team approach – who involved Disease Registers Accurate identification of patients Identifying data Strategies for finding patients Which model of care Holistic approach Call and recall systems Evidence based interventions

Some Issues Points will be important Some hard to get Team work Admin support Working smarter Data extraction from outside sources Tight registers Systematic approach

StandardPointsMax Threshold NowPoints Now What do we need to doWho Register (242)5********  5Current system. Check READ coding. ? Proactive searching amongst smokers. D/N PIO Confirmed by spirometry since 11/4/03 590%44% (9) 0Protocol needed/call/recall Increased use Spirometry- before diagnosis especially smokers. Additional nurse training. D/N (Nurses) PIO Spirometry ??? 590%4%0Consider recall for all COPD pts especially those without spirometry. Spirometry from 2º sources will need extracting and READ coding. Smoking status recorded in last 15 months. 690%52%3As per CHDPIO D/N S.W Smoking advice offered past 15/12 690%13%0As per CHD FEVI in last 27/12 670%<1%0Protocol needed. Nurse training call/recall. Inhaler technique checked last 2 years 690%14%1As above. Flu vacc.685%81%6 Total Points45 Would Currently Obtain15

StandardPointsMax Threshold NowPoints Now What do we need to doWhoImportant READ codes Register of those with DM 6********  6Current system adequate. Use correct read codes. PIO D/N L.N With BMI last 15/12 390%86%3Current protocol. Extract data from 2º source. Consider seeing those seen in 2º care for mini check. PIO D/N Record smoking status 390%53.3 % 2Current protocol ? Mail shot letter PIO D/N Advice offered590%26.8 % 1As per CHDPIO D/N S.W Secr. With ? last 15/12 390%84%3Current protocol Extract data from 2º sources. PIO D/N L.N HbA1c less than 7.4 last 15/ %48%16Current protocol.D/N HbA1c less than %81%11Current protocol.D/N Retinal screening last 15/12 590%75%4Current protocol. Ensure correct read code entry ? Those in 2º care ? Practice letter. PIO D/N L.N Quality Indicators | Domain- Diabetes

Penpheral pulses checked 390%80%2Current protocol. ? Those in 2º care mini check D/N Neuropathy testing. 390%74%2Protocol as for pulsesD/N BP390%92%3Protocol Extract data from 2º sources. Ensure all BP in dedicated field. PIO D/N L.N Last BP < 145/851755% 17Current protocol- as above.D/N Microalbumin last 15/12 390%<1%0Extend current protocol. ? Lab. D/N Creat last 15/12390%73%2Current protocol. ? Check for those in 2º care. Ensure extraction of 2º data PIO D/N L.N With proteinuria/ microalb on ACE 370%55%2Extend protocolD/N Cholesterol last 15/12 390%65%2Extend protocol to over 75D/N <5mmols660%32%3Extend protocol to over 75- change protocol DM considered as 2º prev. D/N Flu vacs last season 385%60%2Focus on under 65 ? Individual letter. Clinic PIO S.W Total points99 Would Currently Obtain81