Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data

Background

In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.

Aim

To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.

Design of the study

Cross-sectional analysis of routine data.

Setting

English general practice in 2005/2006.

Method

QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.

Results

A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA_1C] ≤7.4%, HbA_1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).

Conclusion

Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.     

Developing performance indicators for primary care: Walsall's experience

Background

There has been increasing interest in the development of performance indicators in primary care, especially since the introduction of the Quality and Outcomes Framework (QOF). Public health and primary care trusts collect a range of data from routine or non-routine sources that may be useful for this purpose.

Aim

To assess whether performance against the QOF is a robust measure of practice performance when compared with health-inequality indicators and to contribute to the development of a tool to monitor and improve primary care services.

Design of study

A retrospective cross-sectional study.

Setting

Sixty-three GP practices contracted with Walsall Teaching Primary Care Trust.

Method

Correlation analysis and scatter plots were used to identify possible significant relationships between QOF scores and health-inequality data. The study also utilised confidence limit theory and control chart methodology as tools to identify possible performance outliers.

Results

Little correlation was found between overall QOF score and deprivation score. Uptake of flu immunisation (r² = 0.22) and cervical screening (r² = 0.11) both showed a slight increase with increased QOF score. Benzodiazepine (r² = 0.06) and antibiotic prescribing levels (r² = 0.02) decreased slightly with increased QOF scores, although not significantly. An increase in practice-population deprivation score was correlated with a reduction in cervical screening uptake (r² = 0.27) and an increase in benzodiazepine prescribing (r² = 0.25). Statistically significant relationships were found between the patient: GP ratio and flu immunisation uptake (r² = 0.1) and antibiotic prescribing (r² = 0.1). The majority of GPs found it acceptable to use performance indicator data as part of their annual appraisal.

Conclusion

QOF and health-inequality data can be used together to measure practice performance and to develop tools to help identify areas for performance development and the sharing of best practice.     

Exception reporting in the Quality and Outcomes Framework: views of practice staff �C a qualitative study

Background

Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a ‘gaming’ mechanism.

Aim

To explore GP and practice staff views and experiences of exception reporting in the QOF.

Design of study

Qualitative semi-structured interviews.

Setting

Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.

Method

Semi-structured interviews, analysed using open explorative thematic coding.

Results

Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an ‘exception to the rule’ that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by ‘other’ practices. Only two GPs admitted to occasional inappropriate exception reporting.

Conclusion

Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism.     

Impact of the QOF and the NICE guideline in the diagnosis andmanagement of depression: a qualitative study

Background

The National Institute for Health and clinical Excellence (NICE) depression guideline (2004) and the updated Quality and Outcomes Framework (QOF) ( 2006) in general practice have introduced the concepts of screening severity assessment, for example using the Patient Health Questionnaire 9 (PHQ-9), and ‘stepped care’ for depression.

Aim

To explore primary care practitioner perspectives on the clinical utility of the NICE guideline and the impact of the QOF on diagnosis and management of depression in routine practice.

Design and setting

Qualitative study using focus groups from four multidisciplinary practice teams with diverse populations in south Yorkshire.

Method

Four focus groups were conducted, using a topic guide and audiotaping. There were 38 participants: GPs, nurses, doctors in training, mental health workers, and a manager. Data analysis was iterative and thematic.

Results

The NICE guideline, with its embedded principles of holism and evidence-based practice, was viewed positively but its impact was compromised by resource and practitioner barriers to implementation. The perceived imposition of the screening questions and severity assessments (PHQ-9) with no responsive training had required practitioners to work hard to minimise negative impacts on their work, for example: constantly adapting consultations to tick boxes; avoiding triggering open displays of distress without the time to offer appropriate care; positively managing how their patients were labelled. Further confusion was experienced around the evolving content of psychological interventions for depression.

Conclusion

Organisational barriers to the implementation of the NICE guideline and the limited scope of the QOF highlight the need for policy makers to work more effectively with the complex realities of general practice in order to systematically improve the quality and delivery of ‘managed’ care for depression.     

Views of cancer care reviews in primary care: a qualitative study

Background

The Quality and Outcomes Framework (QOF) provides an incentive for practices to establish a cancer register and conduct a review with cancer patients within 6 months of diagnosis, but implementation is unknown.

Aim

To describe: (1) implementation of the QOF cancer care review; (2) patients'' experiences of primary care over the first 3 years following a cancer diagnosis; (3) patients'' views on optimal care; and (4) the views of primary care professionals regarding their cancer care.

Design of study

Qualitative study using thematic analysis and a framework approach.

Setting

Six general practices in the Thames Valley area.

Method

Semi-structured interviews with cancer patients and focus groups with primary care teams.

Results

Thirty-eight adults with 12 different cancer types were interviewed. Seventy-one primary care team members took part in focus groups. Most cancer care reviews are conducted opportunistically. Thirty-five patients had had a review; only two could recall this. Patients saw acknowledgement of their diagnosis and provision of general support as important and not always adequately provided. An active approach and specific review appointment would legitimise the raising of concerns. Primary care teams considered cancer care to be part of their role. GPs emphasised the importance of being able to respond to individual patients'' needs and closer links with secondary care to facilitate a more involved role.

Conclusion

Patients and primary care teams believe primary care has an important role to play in cancer care. Cancer care reviews in their current format are not helpful, with considerable scope for improving practice in this area. An invitation to attend a specific appointment at the end of active treatment may aid transition from secondary care and improve satisfaction with follow-up in primary care.     

Patients' views of pay for performance in primary care: a qualitative study

Background

Many countries use pay-for-performance schemes to reward family practices financially for achieving quality indicators. The views of patients on pay for performance remain largely unexplored.

Aim

To gain the views of family practice patients on the United Kingdom pay-for-performance Quality and Outcomes Framework (QOF).

Design and setting

Interviews with 52 patients were conducted in 15 family practices across England. All patients had at least one long-term condition that had been diagnosed before the introduction of the QOF in 2004.

Method

Semi-structured interviews analysed using open explorative thematic coding.

Results

Few patients had heard of the QOF or had noticed changes to the structure or process of their care. However, where they were noted, changes to consultations such as increased use of computers and health checks initiated by the GP or practice nurse were seen as good practice. The majority of patients were surprised to hear their practice received bonuses for doing ‘simple things’. Some patients also raised concerns over potential unintended consequences of pay-for-performance frameworks, such as a reduced focus on non-incentivised areas.

Conclusion

This study adds a unique patient perspective to the debate around the impact of pay-for-performance schemes and consequences on patient care. Patients'' views, experiences, and concerns about pay for performance mostly chime with previously described opinions of primary care staff. Patient surprise and concern around incentivising basic processes of care shows how patient views are vital when monitoring and evaluating a scheme that is designed to improve patient care.     

Do the Quality and Outcomes Framework patient experience indicators reward practices that offer improved access?

Background

The Quality and Outcomes Framework (QOF) includes indicators for patient experience, but there has been little research on whether the indicators identify practices that deliver good patient access.

Aim

To determine whether practices that achieved high QOF patient experience points in 2005/2006 or 2006/2007 also delivered good patient access.

Design of study

Use of publicly available data to investigate two hypotheses: practices with more positive access survey findings in 2006/2007 will be more likely to have achieved maximum QOF patient experience points in the same year; and practices with maximum QOF patient experience points in 2005/2006 will have higher access survey findings in 2006/2007.

Setting

Two-hundred and twenty-four East Midlands general practices.

Method

For hypothesis one, binary logistic regression was used, with achievement of maximum QOF points as the dependent variable, and access survey findings, responder variables, and practice variables as independent variables. For hypothesis two, general linear models were used, with access survey findings as the independent variables, and achievement of maximum QOF points and the responder and practice variables as dependent variables.

Results

The findings did not support the first hypothesis. For the second hypothesis, achievement of maximum QOF points was only significantly associated with patient satisfaction with opening hours (positive correlation). QOF points were not associated with any other aspect of access.

Conclusion

The QOF patient experience indicators do not reward practices that offer good patient access. A standard patient survey with financial incentive may be more effective in identifying and rewarding practices that offer better access, including opportunity to book appointments with a particular doctor.     

Questionnaire severity measures for depression: a threat to the doctor–patient relationship?

Background

Since 2006 the Quality Outcomes Framework (QOF) has rewarded GPs for carrying out standardised assessments of the severity of symptoms of depression in newly diagnosed patients.

Aim

To gain understanding of GPs'' opinions and perceived impact on practice of the routine introduction of standardised questionnaire measures of severity of depression through the UK general practice contract QOF.

Design of study

Semi-structured qualitative interview study, with purposive sampling and constant comparative analysis.

Setting

Thirty-four GPs from among 38 study general practices in three sites in England, UK: Southampton, Liverpool, and Norfolk.

Method

GPs were interviewed at a time convenient to them by trained interviewers. Interviews were audiorecorded and transcribed verbatim in preparation for thematic analysis, to identify key views.

Results

Analysis of the interviews suggested that the use of severity questionnaires posed an intrusion into the consultation. GPs discursively polarised two technologies: formal assessment versus personal enquiry, emphasising the need to ensure the scores are used sensitively and as an aid to clinical judgement rather than as a substitute. Importantly, these challenges implicitly served a function of preserving GPs'' identities as professionals with expertise, constructed as integral to the process of diagnosis.

Conclusion

GP accounts indicated concern about threats to patient care. Contention between using severity questionnaires and delivering individualised patient care is significantly motivated by GP concerns to preserve professional expertise and identity. It is important to learn from GP concerns to help establish how best to optimise the use of severity questionnaires in depression.     

Primary care quality indicators for children: measuring quality in UK general practice

Background

Child health care is an important part of the UK general practice workload; in 2009 children aged <15 years accounted for 10.9% of consultations. However, only 1.2% of the UK’s Quality and Outcomes Framework pay-for-performance incentive points relate specifically to children.

Aim

To improve the quality of care provided for children and adolescents by defining a set of quality indicators that reflect evidence-based national guidelines and are feasible to audit using routine computerised clinical records.

Design and setting

Multi-step consensus methodology in UK general practice.

Method

Four-step development process: selection of priority issues (applying nominal group methodology), systematic review of National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) clinical guidelines, translation of guideline recommendations into quality indicators, and assessment of their validity and implementation feasibility (applying consensus methodology used in selecting QOF indicators).

Results

Of the 296 national guidelines published, 48 were potentially relevant to children in primary care, but only 123 of 1863 recommendations (6.6%) met selection criteria for translation into 56 potential quality indicators. A further 13 potential indicators were articulated after review of existing quality indicators and standards. Assessment of the validity and feasibility of implementation of these 69 candidate indicators by a clinical expert group identified 35 with median scores 8 on a 9-point Likert scale. However, only seven of the 35 achieved a GRADE rating >1 (were based on more than expert opinion).

Conclusion

Producing valid primary care quality indicators for children is feasible but difficult. These indicators require piloting before wide adoption but have the potential to raise the standard of primary care for all children.     

The Public Health Impact score: a new measure of public health effectiveness for general practices in England

Background

Health policy in the UK is increasingly focused on the measurement of outcomes rather than structures and processes of health care.

Aim

To develop a measure of the effectiveness of primary care in terms of population health outcomes.

Design and setting

A cross-sectional study of general practices in England.

Method

Twenty clinical quality of care indicators for which there was evidence of mortality reduction were identified from the national Quality and Outcomes Framework (QOF) pay-for-performance scheme. The number of lives saved by 8136 English practices (97.97% of all practices) in 2009/2010 was estimated, based on their performance on these measures, and a public health impact measure, the PHI score, was constructed. Multilevel regression models were used to identify practice and population predictors of PHI scores.

Results

The mean estimated PHI score was 258.9 (standard deviation [SD] = 73.3) lives saved per 100 000 registered patients, per annum. This represents 75.7% of the maximum potential PHI score of 340.9 (SD = 91.8). PHI and QOF scores were weakly correlated (Pearson r = 0.28). The most powerful predictors of PHI score were the prevalence of the relevant clinical conditions (β = 0.77) and the proportion of patients aged ≥65 years (β = 0.22). General practices that were less successful at achieving their maximum potential PHI score were those with a lower prevalence of relevant conditions (β = 0.29), larger list sizes (β = −0.16), greater area deprivation (β = −0.15), and a larger proportion of patients aged ≥65 years (β = −0.13).

Conclusion

The PHI score is a potential alternative metric of practice performance, measuring the estimated mortality reduction in the registered population. Rewards under the QOF pay-for-performance scheme are not closely aligned to the public health impact of practices.     

Increasing the QOF upper payment threshold in general practices in England: impact of implementing government proposals

Background

General practices in the UK receive incentive payments for managing patients with selected chronic conditions under the Quality and Outcomes Framework (QOF) scheme. Payments are made when a negotiated threshold percentage of patients receive the appropriate intervention.

Aim

From 2013–2014 in England the Department of Health has proposed that this negotiated threshold is replaced with a value equal to the 75th percentile of national performance to attract maximum payments. This is an investigation of the potential impact of this change on practice income and workload.

Design and setting

Analysis of 2011–2012 QOF dataset (the latest available) which covers 8123 GP practices and 55.5 million patients in England.

Method

The 75th percentile of performance was calculated for 52 clinical indicators and applied to 2011–2012 performance. Estimations were made of financial and workload impacts on practices, and whether practices with different characteristics would be disproportionately affected.

Results

The proposed changes will result in an increase in the upper payment threshold of each clinical indicator by a mean of 7.47% (range 2.16–38.87%). If performance remains static practices would lose a mean of 47.68 (0–108.33) QOF points, equivalent to a mean financial change of −£279.60 (−£35 352.50 to +£19 957.78) per practice for these 52 indicators.

Conclusion

Increasing the QOF upper payment threshold to the 75th percentile of national performance will, if clinical performance remains static, substantially reduce the mean number of QOF points achieved per practice. However, this translates into only a small mean loss of income per practice.     

Patient-reported areas for quality improvement in general practice: a cross-sectional survey

Background

GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.

Aim

To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.

Design and setting

Cross-sectional survey of patients attending Australian general practice clinics.

Method

Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.

Results

In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).

Conclusion

Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required.     

Primary Medical Care Provider Accreditation (PMCPA): pilot evaluation

Background

While practice-level or team accreditation is not new to primary care in the UK and there are organisational indicators in the Quality and Outcomes Framework (QOF) organisational domain, there is no universal system of accreditation of the quality of organisational aspects of care in the UK.

Aim

To describe the development, content and piloting of version 1 of the Primary Medical Care Provider Accreditation (PMCPA) scheme, which includes 112 separate criteria across six domains: health inequalities and health promotion; provider management; premises, records, equipment, and medicines management; provider teams; learning organisation; and patient experience/involvement, and to present the results from the pilot service evaluation focusing on the achievement of the 30 core criteria and feedback from practice staff.

Design of study

Observational service evaluation using evidence uploaded onto an extranet system in support of 30 core summative pilot PMCPA accreditation criteria.

Setting

Thirty-six nationally representative practices across England, between June and December 2008.

Method

Study population: interviews with GPs, practice managers, nurses and other relevant staff from the participating practices were conducted, audiotaped, transcribed, and analysed using a thematic approach. For each practice, the number of core criteria that had received either a‘good’or‘satisfactory’rating from a RCGP-trained assessment team, was counted and expressed as a percentage.

Results

Thirty-two practices completed the scheme, with nine practices passing 100% of core criteria (range: 27–100%). There were no statistical differences in achievement between practices of different sizes and in different localities. Practice feedback highlighted seven key issues: (1) overall view of PMCPA; (2) the role of accreditation; (3) different motivations for taking part; (4) practice managers dominated the workload associated with implementing the scheme; (5) facilitators for implementation; (6) patient benefit — relevance of PMCPA to quality improvement; (7) recommendations for improving the scheme.

Conclusion

Version 1 of PMCPA has been piloted as a primary care accreditation scheme and shown to be relevant to different types of practice. The scheme is undergoing revision in accordance with the findings from the pilot and ongoing consultation.     

Chronic disease detection and access: does access improve detection,or does detection make access more difficult?

Background

The recorded detection of chronic disease by practices is generally lower than the prevalence predicted by population surveys.

Aim

To determine whether patient-reported access to general practice predicts the recorded detection rates of chronic diseases in that setting.

Design and setting

A cross-sectional study involving 146 general practices in Leicestershire and Rutland, England.

Method

The numbers of patients recorded as having chronic disease (coronary heart disease, chronic obstructive pulmonary disease, hypertension, diabetes) were obtained from Quality and Outcomes Framework (QOF) practice disease registers for 2008–2009. Characteristics of practice populations (deprivation, age, sex, ethnicity, proportion reporting poor health, practice turnover, list size) and practice performance (achievement of QOF disease indicators, patient experience of being able to consult a doctor within 2 working days and book an appointment >2 days in advance) were included in regression models.

Results

Patient characteristics (deprivation, age, poor health) and practice characteristics (list size, turnover, QOF achievement) were associated with recorded detection of more than one of the chronic diseases. Practices in which patients were more likely to report being able to book appointments had reduced recording rates of chronic disease. Being able to consult a doctor within 2days was not associated with levels of recorded chronic disease.

Conclusion

Practices with high levels of deprivation and older patients have increased rates of recorded chronic disease. As the number of patients recorded with chronic disease increased, the capacity of practices to meet patients'' requests for appointments in advance declined. The capacity of some practices to detect and manage chronic disease may need improving.     

Presentation and outcome of clinical poor performance in one health district over a 5-year period: 2002–2007

Background

The detection, assessment, and management of primary care poor performance raise difficult issues for all those involved. Guidance has largely focused on managing the most serious cases where patient safety is severely compromised. The management of primary care poor performance has become an increasingly important part of primary care trust (PCT) work, but its modes of presentation and prevalence are not well known.

Aim

To report the prevalence, presentation modes, and management of primary care poor performance cases presenting to one PCT over a 5-year period.

Design of study

A retrospective review of primary care poor performance cases in one district.

Setting

St Helens PCT administered 35 practices with 130 GPs on the performers list, caring for 190 110 patients in North West England, UK.

Method

Cases presenting during 2002–2007 were initially reviewed by the chair of the PCT clinical executive committee. Anonymised data were then jointly reviewed by the assessor and another experienced GP advisor.

Results

There were 102 individual presentations (20 per year or one every 2–3 weeks) where clinician performance raised significant cause for concern occurred over the 5-year period. These concerns related to 37 individual clinicians, a range of 1–14 per clinician (mean 2.7). Whistleblowing by professional colleagues on 43 occasions was the most common presentation, of which 26 were from GPs about GPs. Patient complaints (18) were the second most common presentation. Twenty-seven clinicians were GPs, of whom the General Medical Council (GMC) were notified or involved in 13 cases. Clinicians were supported locally, and remedying was exclusively locally managed in 14 cases, and shared with an external organisation (such as the GMC or deanery) in another 12.

Conclusion

Professional whistleblowing and patient complaints were the most common sources of presentation. Effective PCT teams are needed to manage clinicians whose performance gives cause for concern. Sufficient resources and both formal and informal ways of reporting concerns are essential.     

Patient and professional views of open access hysterosalpingography for the initial management of infertility in primary care

Background

Hysterosalpingography (HSG) is recommended as a first-line investigation for tubal assessment of infertile women. This investigation is not routinely available to GPs.

Aim

To explore the perceptions and attitudes of patients and health professionals to open access HSG for the initial management of infertile couples in general practice.

Design of study

A nested qualitative study using in-depth interviews with GPs, fertility specialists, and infertile couples.

Setting

Northumberland, Newcastle upon Tyne, North Tyneside, South Tyneside, and Gateshead.

Method

Participants were 39 interviewees: 12 GPs, five fertility specialists, and 13 infertile couples (nine interviewed with their partner).

Results

Four themes emerged: personal factors; will it benefit patients, GPs, and fertility specialists?; professional factors; does it fit the role of a GP?; local context; do the skills exist in general practice?; and wider context; will it benefit the NHS? GPs who had used open access HSG, felt it was appropriate for general practice and would continue to use the service. All GPs, fertility specialists, and infertile couples who had experienced open access HSG wished the service to remain in place. The main barriers to its uptake were: infrequency with which infertility presents; lack of clarity on perceived responsibilities; difficulty keeping up to date, including assimilating guidelines; low clinical priority; and lack of support in authoritative guidance.

Conclusion

Providing GPs with open access to HSG would allow a full initial assessment of the infertile couple and refer women with blocked tubes directly to tertiary care. While there is general support for the provision of such a facility, the majority of GPs perceive its use as being by a limited number of GPs who have a special interest in infertility. The study findings can inform future development of infertility services at the interface between primary and secondary/tertiary care.