Feedback on Healthcare Standards/Quality Schedule

Proposed Changes to Healthcare Commission

OQF Annual Report 2007/08

Changes to QOF 2008/09

Reflection

Standards and QOF Updates GP CG Leads Meetings June 2008

Julie Wilkinson,Head of Clinical Governance

Feedback on Quality Schedule

Profession Yes No Not applicable

No response

GP 79 2 10 9

Dentist 79 3 12 6

Pharmacists 72 3 16 9

Optometrists 69 14 12 5

Resource packs to follow – policies, web links etc

Proposed Changes to Healthcare Commission

Consultation until 17 June to establish new regulator for health and adult social care – Care Quality Commission (October 2008)

Purpose – to ensure services are safe, that people are not put at risk and that standards are maintained.

Propose that primary care services will have to register – single system of registration requirements to replace Standards for Better Health (but Standards will be transferred into new registration requirements).

Without registration (to be introduced in 2010) will be illegal to provide services that are in the scope of registration

Enforcement action will be taken where non-compliance with essential levels of safety and quality.

Propose using existing arrangements as evidence of compliance eg contract monitoring, Performers List, QOF and prescribing data

QOF Annual Report 07/08Achievement• average Practice achieved 972.07/1000, with all but 8

Practices achieving more than 95% • range of points achieved was 855.47 – 1000

(excluding 3 Practices where the end of year QMAS figures are not yet available)

• PCT Avg points in 2006/7 was 947.23 and in 2007/8 is 972.07

Despite many Practices commenting that the new process was more challenging, note average achievements have increased.

Key Themes

• Need clear and robust process • Verification of registers (high or low)• Verification of exception reporting• Check indicators to QOF standards (eg

clinical reviews)• High challenge and high support results

in improved quality and knowledge and ensure fairness for all

QOF Annual Report 07/08

Practice Visits• 7 Practices offered and accepted an informal visit re

profiling issues• 11 Practices were identified as needing a Formal

QOF Review Visit • 3 formal Practices some issues remained unresolved

after PPV process

Practice Feedback-post QOF• Majority of practices very clear about PCT

process and reasons for visit• Only 1 practice expressed concerns about

their visit• All Practices reported that actions

resulting from Visits were reasonable to verify QOF points -‘Mostly’ 82% and ‘Absolutely’ 18%

• Large majority found process highly challenging, supportive, fair and robust

Prevalence25 Practices asked to review disease prevalence on at least one of their

registers. Checked at PPV – 22 Practices had made noticeable changes

• Practice of 8000 – low palliative care register increased from 3-33, depression from 19 to 129, CKD from 124 to 329 and obesity from 456 to 623

• Practice of 2000 patients low CKD register increased from 1 to 30• Practice of 2500 patients low diabetes increased from 37 to 78, CKD

from 3 to 50• Practice with 10,000 patients low epilepsy increased from 18 to 31,

hypothyroid 100 to 263, palliative from 3 to 15, asthma from 565 to 614 and CKD from 93 to 147

• Practice of 3000 patients high asthma register reduced from 253 to 197

• Practice of 2000 patients high CHD register reduced from 105 to 83 and hypertension from 258 to 220

Number of Patients in Beds PCT on CKD register

6000

6500

7000

7500

8000

8500

9000

9500

10000

Apr-07 May-07 J un-07 J ul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 J an-08 Feb-08 Mar-08

Month

Number on register

PCT and National Average Prevalences

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Domain

% P

reva

len

ce

PCT Prev 07/08

National Prev 07/08

Exception Reporting

• In 24 Practices raised at profiling then reviewed at the Pre Payment Verification check.

• 17 Practices had made significant changes and 2 had verified their use of the codes. – Reduction in use of ‘Maximum tolerate dose’– Often ‘unsuitable’ used when should be ‘patient dissent’– One practice identified 55/99 patients where

exception or diagnosis code was incorrect

• 5 Practices audited this and asked to review exception protocol in line BMA guidance but no significant changes noted at PPV - will be raised with the Practice again this year.

Checking to QOF StandardsPCT Mental

HealthCancer Dementia

% where standards not met Sept 07

Bedfordshire 47% 39% 55%

Former Bedford 25% 21% 30%

Former Heartlands

63% 52% 74%

  % where standards not met and payments therefore not made March 08

Bedfordshire 10% 10% 23%

QOF – What Value?

Majority of Practices have now really embedded QOF into the delivery of high quality care. Not seen as an add-on.

Some Practices still see some aspects of QOF as a tick-box exercise.

What impact has QOF had on patient care?

Indicator Description % in 2004/5 % 2005/6 % 2006/7 % 2007/8CHD 1 Prevalence of CHD 2.99 2.99 3.07 3.06CHD 6 BP <150/90 in last 15 mths 85.44 87.22 88.28 89.53CHD 8 Cholesterol <5 mmol/l last 15 mths 74.65 81.6 84.17 84.12Stroke 1 Prevalence of Stroke 1.2 1.25 1.33 1.36Stroke 6 BP <150/90 in last 15 mths 81.11 83.46 87.7 85.71Stroke 8 Cholesterol <5 mmol/l last 15 mths 61.91 71.15 77.21 76.56Diabetes 1 Prevalence of Diabetes 3.26 3.42 3.54 3.76Diabetes 6/20 HBA1C <=7.4 last 15 mths 56.54 58.62 59.76 60.72Diabetes 7 HBA1C <=10 last 15 mths 89.46 91.01 89.56 91.05Diabetes 12 BP <145/85 in last 15 mths 68.62 71.26 74.23 76.89Diabetes 17 Cholesterol <5 mmol/l last 15 mths 69.21 76.87 81.65 81.5

Indicator Description % in 2004/5 % 2005/6 % 2006/7 % 2007/8

% Prevalence / Achievement

% Prevalence / Achievement

Indicator Description % in 2004/5 % 2005/6 % 2006/7 % 2007/8Epilepsy 1 Prevalence of Epilepsy 0.51 0.52 0.49 0.53Epilepsy 4 / 8 Convulsion free 12 mths 69.16 73.77 74.75 72.91Hypertension 1 Prevalence of Hypertension 10.72 11.27 12.06 12.34Hypertension 4 BP recorded in last 9 mths 91.65 92.55 92.34 92.54Hypertension 5 BP<150/90 in last 9 mths 72.24 74.58 77.58 78.4CKD 1 Prevalence of CKD 1.6 2.28CKD 2 BP recorded in last 15 mths 97.95 98.22CKD 3 BP<140/85 in last 15 mths 83.38 73.24Asthma 6 Asthma review conducted in last 15 mths 73.5 76.13 78.02 79.51

% Prevalence / Achievement

Finance

• Total achievement payment across the PCT 2007/08 was £7,974,526.31. PCT funding was £6,443,000 (gap of £1,531,526)

• During the PPV process points were deducted where evidence not available or verified = £27,450.23 over both clinical and organisational domains

Any questions?

Changes to the Quality Outcomes Framework for the

financial year 2008/09

58.5 QOF points (38.5 from the holistic, clinical and organisation domains, plus 20 points from the patient experience domain) will be reallocated to reward patient satisfaction with Access, through new QOF indicators in the patient experience domain.

58.5 QOF points will be dependent on the results of access questions contained within a new national patient survey on 48 hours access and advanced booking.

QOF Points

National Prevalence Day

This would move to the 31st March from 31/03/09 onwards in order that prevalence should be calculated on the same basis as disease registers for indicator denominators.

Calculating year-end payments

• The deadline for year end achievement payments extended to the end of the first quarter of the financial year following the year in question.

• To compensate for any effect on cash-flow for contractors, aspiration payments made during 2008/09 would increase from 60 to 70% achievement in 2007/08.

Points to be released

COPD 9: the negotiators have agreed to replace this indicator with a new indicator reflecting NICE guidance and requiring 5 less points.

Indicators PointsHolistic care bonus 20Information 3 1Information 7 1.5Education 4 3Management 4 1Management 6 2Management 8 1Medicine 7 4COPD 9 (remaining points) 5Total 38.5

  

New Patient Experience Indicators

1. The percentage of patients who, using the national GP patient survey, indicate that they were able to obtain an appointment at their GP surgery within 48 hours.

2. The percentage of patients who, using the national GP patient survey, indicate that they were able to book an appointment with their GP more than 2 days ahead.

Two new indicators to reward of 48 hour appointments and advance booking, replacing PE 5 and will be funded from the 20 points released from PE 5 plus the 38.5 points released (previous slide) giving total of 58.5 points. Exact wording of the indicators yet to be agreed, but PE 7 and PE 8 will measure the following aspects of patient satisfaction:

Patient Survey

• PE1, 2 and 6 will remain. PE 2 will continue to reward practices for carrying out an approved local patient survey.

• Achievement of PE6 will continue to reward practices for producing an action plan as set out in the indicator. Achievement of PE6 will continue to be dependent on achievement of PE2.

Further changes to QOF indicators

Smoking Add patients on the QOF Mental Health and Chronic Kidney Disease registers to target population for smoking 1.

“Never smoked status” to be checked and recorded annually until the patient is aged 25 years or over. Ex-smokers to be asked about smoking status on an annual basis until they have been a non-smoker for 3 years.

The Devil is in the codes – we don’t yet know what the code will be for ‘ex-smoker who is now more than 3 years ex and over 25 yrs.

Further changes to QOF indicators

Chronic Obstructive Pulmonary Disease • New indicator COPD 12 to replace COPD 9 and bring in line

with NICE guidance.COPD 12: The percentage of patients with COPD diagnosed

after 1.4.08 in whom the diagnosis has been confirmed by post bronchodilator spirometry. (5 points)

So must do reversibility on all new diagnoses (that’s what ‘post bronchodilator’ implies), no point doing ‘post’ if you haven’t done ‘pre’ therefore you must have the figures to do reversibility percentage. As not yet clear what the codes will be it is sensible to use the current reversibility codes.

Chronic Kidney DiseaseCKD4 to be amended and renumbered as CKD5 to only include those patients with hypertension and proteinuria (as detailed in the CKD FAQs).

CKD 5: The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded).

StrokeSTROKE11 to be amended to include patients with TIA and be renamed as STROKE13. Timescale for referral to be reduced to 1 month following diagnosis (in line with Expert Panel advice).

STROKE 13: The percentage of new patients with a stroke or TIA who have been referred for further investigation.

 

Palliative Care Register to be amended to include all patients irrespective of age and renamed as PC 3.

 PC 3: The practice has a complete register of all patients in need of palliative care/ support irrespective of age.

Atrial fibrillationQualifying timeframe for ECG assessment to be reduced to 3 months pre and post diagnosis (in line with Expert Panel advice). AF 2 to be renamed as AF 4 and to be prospective from 1 April 08.

Be Aware• Revised Brown Book sent to all Practices 12.6.08• Some changes are subtle• Practices need to understand changes and agree how

to manage them• New Business Rules not yet available – these will

need close scrutiny to ensure appropriate codes used• QMAS currently down for changes to be made so

cannot see current achievement• PCT will arrange for Insight Solutions to provide

training for Practices to learn and question experts about the changes and codes (29 September 2008)

ReflectionQOF has firmly embedded chronic disease management and

electronic patient records into primary care.

Interestingly recent US publication “The Essential Guide to Health Care Quality” states that “only 17% of patients have EPR in US compared to 80% in Netherlands, NZ and UK

And“Chronic disease accounts for 7/10 of all deaths and 70% of total

health care costs. Chronic disease is now widely viewed as one of nations pressing health problems. Many experts agree that providing chronically ill patients with quality care requires adopting a relatively new approach known ‘disease management’”.

Questions?