QOF Quality and Productivity (QP) Indicators Supplementary QP guidance and frequently asked questions for PCOs and practices February 2012
Contents Introduction 2 Summary of QP indicators 3 Outpatient referrals and emergency admissions indicators QP6 to QP11 5 Accident and emergency indicators QP12 to QP14 8 Frequently asked questions 12 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 1
Introduction This document has been jointly produced by NHS Employers and the General Practitioners Committee (GPC) of the BMA. It is intended to assist Primary Care Organisations (PCOs) and practices in understanding and working through the continued and new Quality and Productivity indicators (QP), building on the information in the 2012/13 Quality and Outcomes Framework (QOF) guidance. This guidance applies across the United Kingdom. However, some sections of the guidance are country specific as agreed between the relevant health department and GPC. The detailed 2012/13 QOF guidance is available at: www.nhsemployers.org/payandcontracts/generalmedicalservicescontract/qof/pages/changestoqof2 013.aspx 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 2
Summary of QP indicators Outpatient referrals QP6 QP7 QP8 Indicator The practice meets internally to review the data on secondary care outpatient referrals provided by the PCO. The practice participates in an external peer review with a group of practices to compare its secondary care outpatient referral data either with practices in the group of practices or with practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO. The practice engages with the development of and follows 3 agreed care pathways for improving the management of patients in the primary care setting (unless in individual cases they justify clinical reasons for not doing this) to avoid inappropriate outpatient referrals and produces a report of the action taken to the PCO no later than 31 March 2013. Points 5 5 11 QP9 QP10 QP11 Indicator Emergency admissions The practice meets internally to review the data on emergency admissions provided by the PCO. The practice participates in an external peer review with a group of practices to compare its data on emergency admissions either with practices in the group of practices or practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO. The practice engages with the development of and follows 3 agreed care pathways (unless in individual cases they justify clinical reasons for not doing this) in the management and treatment of patients in aiming to avoid emergency admissions and produces a report of the action taken to the PCO no later than 31 March 2013. Points 5 15 27.5 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 3
Accident and emergency attendances QP12 QP13 QP14 Indicator The practice meets internally to review the data on accident and emergency attendances provided by the PCO no later than 31 July 2012. The review will include consideration of whether access to clinicians in the practice is appropriate, in light of the patterns on accident and emergency attendance. The practice participates in an external peer review with a group of practices to compare its data on accident and emergency attendances, either with practices in the group of practices or practices in the PCO area and agrees an improvement plan firstly with the group and then with the PCO no later than 30 September 2012. The review should include, if appropriate, proposals for improvement to access arrangements in the practice in order to reduce avoidable accident and emergency attendances and may also include proposals for commissioning or service design improvements to the PCO. The practice implements the improvement plan that aims to reduce avoidable accident and emergency attendances and produces a report of the action taken to the PCO no later than 31 March 2013. Points 7 9 15 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 4
Outpatient referrals and emergency admissions indicators QP6 to QP11 The outpatient referrals and emergency admissions indicators require that practices engage with the development of and follow three care pathways in the management and treatment of their patients. The aim is to provide alternative care options for patients in order to avoid inappropriate referrals and emergency admissions. Practices will be required to undertake an internal and external review. In doing this practices will need to consider the data afresh to determine whether improvements that need to be made can be delivered through following the pathways developed in 2011/12 more closely, whether the existing pathways require amending, or whether alternative pathways should be developed. During the external peer review practices should identify any areas for commissioning or service design improvements which are then raised with the PCO when the report is submitted. This could include suggestions about how a referral management centre (if available) is used and if there are any processes that could be improved. In the event that there are no areas for improvement the practice should state this in their report. However, evidence should be provided that the practice has adequately carried out the external peer review. The indicators for outpatient referrals (QP6 and QP7) and emergency admissions (QP9 and QP10) require that a practice undertake an internal review followed by an external peer review. Internal review (QP6 and QP9) PCOs are required to supply practices with data on their secondary care referrals and emergency admissions which a practice reasonably requires to conduct the review(s). In order to assist PCOs in supplying the relevant information to a practice, it may be helpful for the practice and PCO to initially discuss what data is available and how the PCO will supply the relevant information. In doing this, both the practice and PCO will be clear about the expectations regarding the level of data available and when it will be supplied. The internal review should take place at least once during the year with the range of clinicians working in the practice. At the meeting the practice should identify and discuss any apparent anomalies in referral patterns or explore the reasons for emergency admissions, with reference to existing care pathways in order to identify areas where improvements might be made. The output of this review must be made available to the group of practices taking part in the external review. Practices are required to produce and submit a report to the PCO no later than 31 March 2013 that summarises the discussions that have taken place. Scotland In Scotland, if data is not available to allow for the internal review to take place by 30 June 2012, then practices will have eight weeks within receipt of the data in which to have the internal review. The report must be submitted to the Health Board by no later than 15 March 2013. 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 5
External peer review (QP7 and QP10) The external peer review group must consist of a minimum of six practices. A group may only be made up of less than six practices if agreed with the PCO, taking into account local geography and historical groups of practices. At the meeting each practice should be represented by at least one GP. During the external peer review practices should compare their practice data with comparable data from practices in the group, or all practices in the PCO area, to determine why there are any variances and where it may be appropriate to amend management and/or treatment arrangements. For the purpose of QP7 the focus of the review should be to reflect on referral behaviour and whether clinicians can learn from the data to improve their referral practices. In doing this practices should consider their referrals within the context of how to reduce unnecessary hospital attendances, either by following care pathways more closely, or through the use of alternative care pathways. Similarly, for QP10 the focus of the review should be on how practices can amend or improve their treatment and management of patients in primary care to help avoid emergency admissions. Practices could also use the opportunity to recommend to the PCO any areas of commissioning or service design improvements that would enable more effective management of patients in the community and which could help reduce inappropriate referrals or unnecessary hospital attendances or admissions. Practices are required to produce and submit a report to the PCO by no later than 31 March 2013. The report should detail which practices took part in the external review, what discussions took place (this may be in the form of notes/minutes of the meeting) and what areas have been proposed for commissioning or service design improvements. Scotland For Scottish practices the practice groupings will be agreed between the Health Board and the Local Medical Committee (LMC). The report must be submitted to the Health Board by no later than 15 March 2013. Wales For Welsh practices external peer review groups are expected to be those already established by local Health Board s in line with Setting the Direction. Referrals where cancer is suspected The outpatient referrals indicators must not have a negative impact on achieving earlier diagnosis of cancer. Earlier diagnosis might be achieved through an urgent referral via the two week wait pathway or through direct access to diagnostic tests, but at all times the emphasis must be on speedier diagnosis even if it turns out that the patient does not have cancer. A negative diagnosis does not mean that the referral was unnecessary; an unnecessary referral is one where the GP could reasonably and effectively have met the patient s needs in a timely fashion, without referring them for an outpatient appointment. This is extremely unlikely to be the case where cancer is suspected. Guidance on cancer referrals can be found at www.nice.org.uk/cg027 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 6
Delivery of improvements along the care pathways (QP8 and QP11) Three different pathways are required for indicators QP8 and QP11 respectively and where possible should focus on long term conditions. As such, three pathways will be developed for avoiding inappropriate outpatient referrals and three for avoiding emergency admissions. Practices will be required to undertake an internal and external review. In doing this practices will need to consider the data afresh to determine whether improvements that need to be made can be delivered through following the existing pathways developed in 2011/12 more closely, whether the existing pathways require amending or whether alternative pathways should be developed. PCOs working with peer groups, are expected to lead the development of the six care pathways. Where the PCO and peer group consents this can be in consultation with the LMC. If the PCO decides to commission a new pathway that improves quality or productivity, but which involves new and additional workload for primary medical care beyond essential services and outside that required for the achievement of these QOF indicators, then it should resource it separately as a commissioning exercise. GPs in the practice must actively respond to the development process. Achievement of these indicators will be awarded on the basis that practices have engaged in the development of and delivered care along the six care pathways. Practices are required to produce and submit a report to the PCO no later than 31 March 2013. The report should summarise the action taken, information about which care pathways were followed and changes in patterns of referral or rates of emergency admissions. Scotland Scottish practices will be required to include in the report an overview and learning from a reflective analysis. The analysis is to cover 1 per 1000 registered patients up to a maximum of three patients referred along each of the three pathways in the year up until 31 December 2012. The report must be submitted to the Health Board by no later than 15 March 2013. 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 7
Accident and Emergency indicators QP12 to QP14 The accident and emergency (A&E) indicators have been introduced for one year from April 2012 and are aimed at reducing avoidable A&E attendances. These indicators replace the 2011/12 QP indicators on prescribing (QP1, QP2, QP3, QP4 and QP5). To ensure prescribing improvements continue, NHS Employers and GPC negotiators have agreed the following: Although the prescribing element of the quality and productivity scheme will be replaced with A&E attendances in 2012/13, we agree that all practices in the UK should continue to ensure cost effective prescribing when compared to peers, building on the progress achieved in 2011/12. Those practices who remain significant outliers would also be expected to continue to participate in external peer review during 2012/13. As with the outpatient referrals (QP6 and QP7) and emergency admissions (QP9 and QP10) indicators, the A&E attendances indicators (QP12 and QP13) require that a practice undertake an internal review followed by an external peer review. Internal review (QP12) PCOs are required to supply practices with data from the final quarter of the 2011/12 year (1 January to 31 March 2012) on A&E attendances which the practices reasonably requires to conduct the review. The data should, where possible, include patient details, reasons for attendance/diagnosis and the time/date of the attendance. In order to assist PCOs in supplying the relevant information to a practice it may be helpful for the practice and PCO to initially discuss what data is available and how the PCO will supply the relevant information. In doing this both the practice and PCO will be clear about the expectations regarding the level of data available and when it will be supplied. If for whatever reason a PCO is unable to provide the data within a reasonable timeframe that allows practices to meet the indicator deadlines, then it is expected that the PCO will allow practices a longer timeline to complete the review. In such circumstances a decision to allow a longer timeline should be determined locally and clearly agreed between the PCO and practice(s). Practices may wish to reference this in their reports to the PCO for each of the indicators. Any disputes that may arise as a result of this should be dealt with through the normal dispute resolution procedures. Scotland In Scotland, if data is not available to allow for the internal review to take place by 30 June 2012, then practices will have eight weeks within receipt of the data in which to have the internal review. The definition of avoidable attendances should be defined by the practice and agreed with the PCO prior to reviewing the data. Attendances at A&E are defined as those patients seen in a Type 1 A&E department for both first and follow-up attendances for the same condition. Attendances should not include those that are planned or planned follow ups. For example: where a patient has had a prior consultation with their GP for a condition that clearly requires A&E attendance and the GP informs A&E of the impending attendance (e.g. access to specialist/urgent diagnostics/assessment such as an x-ray for suspected fractures and/or admission) where the A&E has booked a follow up appointment if a patient attends the department due to it being where their registered practice is seeing their patients 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 8
if it is the agreed place for a patient to be seen prior to admission. The definition in the document A&E Clinical Quality Indicators Data Definitions published by the Department of Health in England defines a Type 1 A&E department as a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. In circumstances where there is no Type 1 A&E department or where the majority of patients do not use a Type 1 A&E department, then practices and PCOs should agree the most frequently used local urgent care service and agree those that will be included (for example Type 2 and/or Type 3 A&E departments). The type of A&E attendance will be limited to both first and follow-up attendances for the same condition (excluding planned follow-ups). Scotland In Scotland, for Rural Health Boards where the National QOF QP Framework may not easily apply, local flexibility should apply and where appropriate should be agreed between the Health Board and the LMC. Where agreement between the Health Board and the LMC is not reached, for whatever reason, then the Scottish Government Health Department and Scottish GPC will decide jointly. Further information: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_12 2892.pdf The internal review should take place at least once prior to 31 July 2012, or an agreed later date if the data is not made available, with the range of clinicians working in the practice. At the meeting the practice will explore the reasons for registered patients attendance(s) at A&E, identifying any emerging patterns and discussing this with reference to available care pathways and the capability and access within primary care services to see and treat patients. In the discussion, focus should be given to: 1. older patients with co-morbidities at high risk of admission (patients aged 65 years and over) 2. children with minor illness/injury (patients aged 15 years and under) 3. patients who frequently re-attend A&E that could be dealt with in primary care. The review should also specifically consider whether same day access to clinicians in the practice is appropriate and whether any comparisons can be drawn between this and the level of A&E attendances. The output of the review must be made available to the group of practices taking part in the external peer review meeting (QP13). Practices are required to produce and submit a report to the PCO no later than 31 July 2012. It is advised that the report should include the following information: date of meeting and people in attendance a summary of the discussions that took place at the meeting information on what, if any, comparisons have been drawn between same day access to clinicians in the practice and the level of A&E attendances information on the practice s current access arrangements how the practice defined avoidable attendances. 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 9
Practices may wish to include information for discussion at the external peer review meeting, on where improvements may be made to improve the quality of care for patients at the interface of primary care and A&E, in order to help reduce avoidable A&E attendances. In developing the final report, practices may find it useful to refer to the Primary Care Foundation Report Urgent Care - A Practical Guide to Reforming Same Day Care in General Practice published in 2009. The report is available at: www.primarycarefoundation.co.uk/files/primarycarefoundation/downloading_reports/reports_and_ar ticles/urgent_care_centres/urgent_care_may_09.pdf External peer review (QP13) The external peer review group must consist of a minimum of six practices. A group may only be made up of less than six practices if agreed with the PCO, taking into account local geography and historical groups of practices. Where possible the practices should have similar care pathways and/or geographical locations. The group may be the same as that used for the other QP indicators. At the meeting each practice should be represented by at least one GP. During the external peer review practices should compare their practice data with comparable data from practices in the group, or all practices in the PCO area, to determine why there are any variances and where it may be appropriate to amend current arrangements to help reduce avoidable A&E attendances. The focus of the review will be to reflect on the reasons and/or patterns of A&E attendances and identify where improvements may be made to improve the quality of care for patients at the interface of primary care and A&E, in order to help reduce avoidable A&E attendances. Focus should be given to: 1. older patients with co-morbidities at high risk of admission (patients aged 65 years and over) 2. children with minor illness/injury (patients aged 15 years and under) 3. patients who frequently re-attend A&E that could be dealt with in primary care. Practices may also propose, via the peer group, areas for commissioning or service design improvements to the PCOs that could help reduce avoidable A&E attendances. Following the review, the practice improvement plan is either amended or agreed by the group. Practices are required to produce and submit a report to the PCO by no later than 30 September 2012. The report should include the following information: date of meeting and details of practices in attendance a summary of the discussions that took place at the meeting details of the agreed improvement plan that aims reduce avoidable A&E attendances. Wales For Welsh practices external peer review groups are expected to be those already established by local Health Board s in line with Setting the Direction. Implementation of improvement plan (QP14) Practices will be required to implement the arrangements and actions set out in their improvement plans agreed in QP13. In doing this practices will need to review their monthly data to provide information on how improvements in care and primary care access have been made. The report should include information about (1) older patients with co-morbidities at high risk of admission, (2) children with minor illness/injury and (3) patients who frequently re-attend A&E, as well as how any 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 10
improvements in care and access in primary care have helped to reduce avoidable A&E attendances. If the data quality provided to the practice does not allow this to be done for all patients, this should be noted in the report. Evidence to support implementation will be provided to the PCO in the form of a report by no later than 31 March 2013. The report should include the following information: a summary of the details of the improvement plan the action taken to help reduce avoidable A&E attendances information on the three categories of patients (see above) and how improvements in care and primary care access have helped reduce avoidable A&E attendance for these patients. If the data quality provided to the practice does not allow this to be done for all patients, then this should be noted in the report with an explanation as to which patients the data are missing and, if possible, the reasons why. 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 11
Frequently asked questions Care Pathway indicators QP6 to QP11 1. Will there be any national templates available? Templates will not be made available in England and Wales. In Wales, local Health Boards are expected to agree the templates locally with their LMC. In Northern Ireland, templates for internal review, external peer review and end of year reporting areavailable on the HSCB Primary Care intranet under the GMS Contract page. In Scotland, templates for internal review, external peer review and end of year reporting are available. 2. What is the definition of a care pathway? For the purposes of these QP indicators a care pathway is a defined process of diagnosis, treatment and care for a defined group of patients during a defined period. 3. How is the actual delivery of a care pathway to be funded? If the delivery of a care pathway requires additional work beyond that provided under essential services, then the funding for this work should be resourced separately from outside the QOF indicators. The PCO needs to decide first of all whether it should commission the care pathway will it increase the quality or productivity of services for patients? 4. Do the care pathways for QP6 to QP11 have to be newly developed or can they be ones that are currently in development at the time the indicators were published? Practices will be required to undertake an internal and external review. In doing this practices will need to consider the data afresh to determine whether improvements that need to be made can be delivered through following the existing pathways more closely, whether the existing pathways developed in 2011/12 require amending or whether alternative pathways should be developed. 5. Do practices always have to follow care pathways in the treatment of patients if it is not clinically appropriate to do so? Practices must follow the agreed care pathways in the treatment of their patients, unless in individual cases they can justify clinical reasons for not doing this. 6. Do practices within the peer review group have to be in the same PCO area? No. There is no requirement in the QOF guidance/sfe for practices in the external peer review group to be from within the same PCO area. However, the external peer review groups should include practices of similar characteristics, or with similar referral routes or care pathways. Practices may also choose to work within their clinical commissioning groups. 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 12
7. Can practices be represented at the external peer review meeting by another practice s GP or by a practice manager? For indicators QP7, QP10 and QP13, each practice participating in the external peer review meeting should be represented by at least one GP from their own practice. It would be inappropriate for practice managers to represent the practice or for another practice s GP to represent more than their own practice, including single-handed practices. External peer review meetings are expected to be arranged at a time that is convenient for all the practices and should not disrupt patient services. Where a single-handed practice is unable to represent themselves at a external peer review meeting this should be discussed with their PCO. If it requires that the practice manager attends then this would be under extraordinary circumstances and with the agreement of the PCO. This information should, if appropriate, be included in the practice report to the PCO. 8. What period of data should be provided by the PCO for practices to conduct the review meetings? The guidance is not prescriptive about the period of data required to conduct the review meetings and this has been left to local agreement. However, the data supplied should cover a sufficient period to allow for a suitable comparison and it would therefore seem sensible for this not to be less than six months. That said, if the indicators for which this data is required would be related to something that would benefit from a full year s data review, then this should be considered. For example, conditions that could be affect by seasons and therefore result in increased prescribing, referrals or admissions in winter months. 9. What would happen if a practice engages in the development of the three agreed care pathways and then, for whatever reason, one or more of the pathways is withdrawn by the PCO. In such circumstances, it would be considered outside the practice s control if a pathway was withdrawn by the PCO. Providing that the practice can demonstrate that they actively responded to the care pathway development process (see QP 8.1 of the main QOF guidance) then the practice would still be eligible for all the points. The practice will still need to submit the report to the PCO by 31 March 2012 and in the report explain that they were unable to deliver care along the pathway as it was withdrawn. 10. What would happen if a practice engages in the development of three agreed care pathways and then either while following the pathways, the eligible patient(s) leave the practice or the practice has no eligible patients because the pathway chosen was one across a PCO area? If a practice engaged in the development of the pathway and had been delivering care to patient(s) along those lines, but the patient(s) left the practice before the 31 March 2012, then the practice would still be eligible for all the points. The practice will still need to submit the report to the PCO by 31 March 2012 and in the report explain the reasons why they were unable to deliver care along the pathway. In the second example, it is expected that the three pathways chosen would reflect the needs of a practice s patient population. Should a situation arise were one or more of the pathway(s) chosen was PCO/locality wide and the practice has no suitable patients, then the practice would still be eligible for all the points. The practice will still need to submit the report to the PCO by 31 March 2012 demonstrating that they had engaged in the pathway development process and explain the reasons why, for specific pathways, they had no eligible patients to deliver the care to. 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 13
Accident and emergency indicators QP12 to QP14 1. Will there be any national templates available? Templates will not be made available in England and Wales. In Wales, Health Boards are expected to agree the templates locally with their LMC. In Northern Ireland, templates for internal review, external peer review and end of year reporting will be available from April 2012 on the HSCB Primary Care intranet under the GMS Contract page. In Scotland, templates for internal and external peer review end of year reporting are available. 2. In some areas, local GPs run the Minor Injury Units (MIU) and A&E departments. Should patients who attend these types of departments in order to see their own GP for a planned appointment, be included in the data analysis? No, attendances at MIUs or A&E departments that are planned should not be included in the data that is reviewed (see relevant paragraph on pages 8 and 9 above). This includes patients who are directed to attend A&E as part of local emergency admission procedures. The A&E indicators are regarding those attendances that could be considered avoidable because the patient could have been dealt with in primary care. 3. Many practices near A&E departments have service level agreements (SLA) or local enhanced services to provide medical support, treatment and/or assessments. Should this be included in the data analysis? Where services at an A&E department are provided by a practice under a SLA they may choose to use this service to provide routine care for their patients more flexibly. Where this service is provided through a SLA and not a care based contract, then these attendances should not be included in the data analysis. The practice and PCO should take in to account local arrangements that mean patients choose to go to A&E because their own practice GP is working there. 4. What would happen if a SLA or existing LES already covers the three areas practices are required to focus on for the A&E QP indicators? If there is an existing SLA that overlaps with the QP indicators then the PCO may wish to review the contract to take account of this. 5. The guidance explains what should happen if a slippage in timelines leading to a practice missing any of the indicator deadlines, is as a result of the PCO being unable to supply the data. However, if the slippage is as the result of another reason (e.g. the practices unable to find a meeting date before the deadline for QP12 and QP13) then what happens? The decision to accept a slip in meeting the deadlines for QP12 and QP13 is at the PCO s discretion. There are a number of things that both the practice and PCO may wish to consider: Is the reason for the practice being unable to meet the deadline valid If the deadline for either QP12 or QP13 is agreed for extension, both the practice and PCO will need to be mindful that it will reduce the time available for subsequent indicators An agreement to extend the deadline for QP13 may result in the PCO being unable to sign off the practices improvement plan until such time as the external peer review has been completed 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 14
Any disputes arising as a result of a local agreement to change the deadline for QP12 or QP13 will be for the PCO and any disputes should be dealt with through the normal dispute resolution process. 2012/13 Supplementary QP guidance and frequently asked questions for PCOs and practices 15
NHS Employers General Practitioners Committee www.nhsemployers.org www.bma.org.uk enquiries@nhsemployers.org info.gpc@bma.org.uk 29 Bressenden Place British Medical Association London SW1E 5DD BMA House Tavistock Square 2 Brewery Wharf London WC1H 9JP Kendell Street Leeds LS10 1JR Published February 2012. NHS Employers 2012. This document may not be reproduced in whole or in part without permission. The NHS Confederation (Employers) Company Ltd Registered in England. Company limited by guarantee: number 5252407 Ref: EGUI11401