Quality and Outcomes Framework 2007/08

 

Practice Report‘Oaklands’, Middlewich Medical Centre

1. Introduction

 

This report has been prepared following the Quality and Outcomes Framework

Assessment visit undertaken on: Friday 18th January, 2008 at 12.00 noon

The Assessor team consisted of:

Keith Malone, GP Assessor
Jean French, Lay Assessor
Cathy Rowlands, PCT Manager
Dawn Colvin, Primary Care Facilitator

 

Practice representatives were:

Dr M Clifton, GP Partner
Dr J Crofts, GP Partner
Dr D Ford, GP Partner
Dr P Longhorn, GP Partner
Dr T Johnson, GP Partner
Lorraine Carter, Practice Manager
Diane Bowker, Assistant Practice Manager

 

2. Information used during the pre-visit analysis

In preparation for the visit, the Assessor team reviewed the following information:

• Pre-visit evidence submitted by the practice
• QMAS reports
• Apollo QOF Validation Reports
• Information from GPAQ
• Previous QOF reports for the practice
• PCT Validation reports for 2006/7
• Funnel Plots
• Exception reports

3. Review of last year’s achievement

The practice achieved a total of 991.11 points from a maximum of 1000 points for 2006/07. The points achieved were distributed as follows:

	2006/07
Clinical (max. 655)	653.88
Non clinical (max. 345)	337.23

Non clinical indicators not achieved last year are detailed below:

Indicator	Aspiration for this year	Achievement
R22 Smoking status		77%
Medicines 7 (Neuroleptic Medication)	This indicator is unavailable to the practice at this time therefore Practice will not be aspiring to this indicator
R21 Ethnic origin of 100% of new patients recorded		99.65%

4. Apollo Reports

The Apollo reports were reviewed prior to the visit, and the following points noted:

    4.1 Blood Pressure Recording

1. A high number of patients (up to 18%) coded as hypertension who have normal pre-diagnosis BPs.  Those patients incorrectly coded as a result of the previous computer system change will need to be corrected before the next visit.  This had been raised as a problem the previous year and now needs attention as this will be artificially elevating the proportion of hypertensive patients with BP below target.
2. There were a considerable amount of 01/01/1900 dates of diagnosis which indicates that the date of diagnosis has been entered as not known.
3. There was no apparent clustering of reporting dates.
4. 91% of patients on the hypertension register had a BP reading within the last 9 months.
5. 18% of patients on the hypertension register were shown not to be on therapy.

    4.2 Exception Reporting

1. Exception coding appears to be consistent and correct codes are being used.  With the exception of recurrent defaulters, all exception codes are added by a doctor.
2. Group Exceptions – A large number of exceptions were entered on 07/03/07 (cervical smears), 23/03/07 (asthma), 29/03/07 (diabetes) and 28/08/07 (cervical smears).  These were satisfactorily explained due to entries by administration staff as a result of recurrent defaults.

A randomly selected 11 patients had clear indications for exception coding in 9 cases, while it could be seen by extrapolation why one of the other 2 (asthma) had been excepted, in the remaining case (palliative care) it was not clear what had led to the exception coding and time constraints at the visit prevented further

4.2 Review of practice disease prevalence (Funnel Plots)

Disease	PCT Average	National Prevalence	Practice Prevalence	Comments
Coronary Heart Disease	3.84%	3.55%	3.38%	Lower than PCT average
Heart Failure	0.89%	0.79%	0.95%	Higher than PCT average
Stroke/ TIA	1.90%	1.61%	1.78%	Lower than PCT average
Diabetes	3.67%	3.62%	4.43%	Higher than PCT average
Epilepsy	0.57%	0.59%	0.58%	Higher than PCT average
COPD	1.46%	1.42%	2.15%	Higher than PCT average
Asthma	5.59%	5.77%	6.20%	Higher than PCT average.
Hypothyroidism	2.10%	2.49%	2.37%	Higher than PCT average
Cancer	0.98%	0.89%	0.93%	Lower than PCT average
Mental Health	0.71%	0.71%	0.49%	Lower than PCT average
Hypertension	13.43%	12.46%	14.60%	Higher than PCT average

5. Feedback from GP Assessor

Funnel Plots
Hypertension data tidying remains an issue following a change of computer systems which labelled some patients with this diagnosis incorrectly.  The onset dates also defaulted to 1/1/1900 in some cases.

Depression
The practice is still concerned about the clinical value of this part of the QOF and struggles with motivation regarding the use of depression screening tools.

Diabetes patients are screened routinely, CHD patients more likely to be missed as only brought in as part of medication reviews or hypertension follow-up.  A PHQ-9 screening questionnaire with GP follow-up is then administered if the screening questions are positive.

Dementia
The register is developed ad-hoc as and when referral information is created or received by the practice.  It appears to be accurate.  The F2 doctor currently does the nursing home reviews of these patients and others are done ad-hoc and then by formal invite where they have not been seen during the year.  Consistency is ensured by use of a standard template based on the NSF.

Additional comments
Sense that enough members of the practice team had a good working knowledge of the QOF to ensure that patients are well served by the practice.

 

6. Other Indicators reviewed at the visit

6.1            Child Protection
All staff had been trained and all GPs have access to the updated information on the intranet.

6.2            Cervical Cytology
The practice were not aware of the revised guidance contained in the grey booklet distributed by Guy Hayhurst from the Public Health Team but this will be checked with the practice nurses. The practice were advised to check whether the number of patients under 30 presenting for smear tests had fallen since the age had been raised to 25 for first call up.

6.3            Other indictors arising from the folder of evidence
Various indicators were raised at the meeting where the evidence submitted in the folder was not complete.  All of the issues questioned were explained satisfactorily by the practice.

 

6.4            Use of QOF information to inform services
The practice has developed mental health care plans following the mental health reviews required by the QOF and there has been a positive response from patients.  Dr Longhorn examines activity and analyses data.  The practice has made changes resulting from responses to the GPAQ patient questionnaire.  Data and information from the QOF is discussed with all staff at the practice away-day which is held once a year.

 

6.5            Mental Health and Dementia reviews
Some GPs are not happy giving the questionnaire to patients who have been diagnosed elsewhere and were concerned with the accuracy of the information. 

    
     
7.  Patient Experience

 PE1 (Length of consultations)
Appointments are for 10 minutes.  When extra appointments are necessary they are seen at the end of the lists, divided between all doctors on duty.  Appointments were available later on the day of visit and appointments with a particular GP could be obtained within a few days.
    
PE2 Undertaking an approved Patient Survey
PE5 Reflecting on the results of the survey
PE6 Producing an Action Plan on the results

A survey is currently being undertaken, the previous one having been carried out in December 2006.  Questionnaires are being handed out personally in reception with a box for completed returns or a SAE for postal returns.  A good response rate is anticipated (last year’s response estimated at 80+%).  An attempt to obtain a questionnaire in Polish (which it was noted would have been useful last year) was not successful.
A summary of the findings from the 2006 survey including comparison with the previous survey has been produced and the issues raised by patients have been addressed and explanations given.  A new diabetes nurse has been appointed and more diabetic clinics are being held and the recall system has been revamped.  Opening hours have been changed to avoid closure at lunchtime, internet appointment availability has been improved and the touch screen check-in has been amended for ease of use.  A Patient Participation Group has been set up.  Though this has not proved easy, there is a determination to build good links with patients. 

The 2 year action plan set last year has already achieved many priorities.  The lead person for taking this forward is the Practice Manager.  Results of the survey have been shared with patients through the website, information in the surgery and with the new patient participation group.  There is interest in convening a specific focus group, the needs of the recent influx Polish patients being a possible subject.

The National Access Survey showed similar results to the GPAQ survey.  Results have been posted in the waiting room.

 

8. Other indicators reviewed by Lay Assessor

M7 Maintenance Logs
There is a system in place managed by the practice manager and her deputy.  There are schedules for inspection and calibration, and the user of a specific piece of equipment will be alerted when there is a need for action.  There is a system for the reporting of faults.  Although there is clearly a system in place, it would be improved by the addition of more detail to the maintenance schedule so information on all individual items can be quickly and easily accessed.

PM14 Removal from a practice’s list
There is a comprehensive written policy which is used when there is a need to remove a patient from the practice list.  This covers violence, crime, moving out of area, failure to attend appointments and breakdown of doctor-patient relationships.  Letters giving reasons for removal and information on finding a new doctor are used in line with the policy.
    

9. Actions prior to the end of the year.

The following evidence should be shared with the PCT before the end of the year.

PE5 and PE6
Records 9
Meds 11 and 12

10. Conclusion

The practice has a systematic and very well organised approach to QOF. Their past achievement is well deserved, and they are to be congratulated on their commitment to providing a high quality of care to their patients.  There is evidence that a lot of hard work has been undertaken this year, however, the practice are advised to address the points raised by the GP assessor which may have an impact on future data quality.  The practice are to be commended for their protocols and organisational development.

All in all this was a very pleasant and informative visit, the assessment team were made to feel welcome, and thank all concerned for their hospitality.

 

Tel: 01606 836 481   Email: lorraine.carter@gp-n81039.nhs.uk
Middlewich Medical Centre, The Oaklands Medical Centre, St Ann's Walk, Middlewich, Cheshire, CW10 9BE.
Last Updated on Tuesday, 25 August, 2009