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

1. The new GP contract – quality and governance issuesSusan NealNurse-practitioner

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

3. 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

4. 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

5. 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 The four domains of quality

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

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

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

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

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

11. CHD - the biggest marker set - 101 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

12. 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

13. 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

14. 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

15. INDICATOR register of patients smoking status smoking advice BP recorded in last 9 months BP < or = 150/90 COVERAGE POINTS yes/no 9 25-90% 10 25-90% 10 25-90% 20 25-70% 56 Quality points : hypertension

16. 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%

17. Smoking status - Achievement • Points for 90% threshold = 10 • There is also a minimum achievement threshold of 25% • Practice points achieved = (77.78-25)/(90-25) x 10 = 0.812 x 10 • Therefore achievement = 8.12 points

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

19. 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

20. 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

21. Standard Points Max Threshold Now Points Now What do we need to do Who Register (242) 5 ********  5 Current system. Check READ coding. ? Proactive searching amongst smokers. D/N PIO Confirmed by spirometry since 11/4/03 5 90% 44% (9) 0 Protocol needed/call/recall Increased use Spirometry- before diagnosis especially smokers. Additional nurse training. D/N (Nurses) PIO Spirometry ??? 5 90% 4% 0 Consider 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. 6 90% 52% 3 As per CHD PIO D/N S.W Smoking advice offered past 15/12 6 90% 13% 0 As per CHD FEVI in last 27/12 6 70% <1% 0 Protocol needed. Nurse training call/recall. Inhaler technique checked last 2 years 6 90% 14% 1 As above. Flu vacc. 6 85% 81% 6 Total Points 45 Would Currently Obtain 15

22. Standard Points Max Threshold Now Points Now What do we need to do Who Important READ codes Register of those with DM 6 ********  6 Current system adequate. Use correct read codes. PIO D/N L.N With BMI last 15/12 3 90% 86% 3 Current protocol. Extract data from 2º source. Consider seeing those seen in 2º care for mini check. PIO D/N Record smoking status 3 90% 53.3% 2 Current protocol ? Mail shot letter PIO D/N Advice offered 5 90% 26.8% 1 As per CHD PIO D/N S.W Secr. With ? last 15/12 3 90% 84% 3 Current protocol Extract data from 2º sources. PIO D/N L.N HbA1c less than 7.4 last 15/12 16 50% 48% 16 Current protocol. D/N HbA1c less than 10 11 85% 81% 11 Current protocol. D/N Retinal screening last 15/12 5 90% 75% 4 Current protocol. Ensure correct read code entry ? Those in 2º care ? Practice letter. PIO D/N L.N Quality Indicators | Domain- Diabetes

23. Penpheral pulses checked 3 90% 80% 2 Current protocol. ? Those in 2º care mini check D/N Neuropathy testing. 3 90% 74% 2 Protocol as for pulses D/N BP 3 90% 92% 3 Protocol Extract data from 2º sources. Ensure all BP in dedicated field. PIO D/N L.N Last BP < 145/85 17 55% 55% 17 Current protocol- as above. D/N Microalbumin last 15/12 3 90% <1% 0 Extend current protocol. ? Lab. D/N Creat last 15/12 3 90% 73% 2 Current protocol. ? Check for those in 2º care. Ensure extraction of 2º data PIO D/N L.N With proteinuria/ microalb on ACE 3 70% 55% 2 Extend protocol D/N Cholesterol last 15/12 3 90% 65% 2 Extend protocol to over 75 D/N <5mmols 6 60% 32% 3 Extend protocol to over 75- change protocol DM considered as 2º prev. D/N Flu vacs last season 3 85% 60% 2 Focus on under 65 ? Individual letter. Clinic PIO S.W Total points 99 Would Currently Obtain 81