Primary
Care Report
Information
Set
2011
As a requirement of the Annual Quality Framework 2011/12,
Health Boards are required to produce a service improvement and
performance report for Primary Care. This Information Set
provides a range of resources to support the analysis of service
provision.
Promoting
effective and
efficient
services to
improve
health and
patient
experience
2011 Primary Care Report Information Set
Table of Contents
Introduction and context ......................................................................3
Equity.....................................................................................................8
Effectiveness.......................................................................................13
Timeliness ...........................................................................................27
Efficiency.............................................................................................31
Patient experience ..............................................................................34
Safety...................................................................................................38
Annex 1: Sources ...............................................................................42
Annex 2: Glossary of Terms ..............................................................44
2|Page
Introduction and context
This is the second Primary Care Information Set. In 2010/11, the Annual Operating
Framework (AOF) introduced a requirement for Health Boards to develop a Primary
Care Annual Report to:
•
Inform the Board of the processes in place to review and improve primary
care services
•
Provide assurance to the Board in relation to the safety, quality, effectiveness,
timeliness, efficiency and equitable delivery of primary care services
•
Provide the Board with evidence of how patient experience has been captured
and used to further improve the provision of care
•
Inform the Board of the primary care contribution to national programmes
such as the 1000 Lives Campaign
Whilst the Annual Quality Framework (AQF) has replaced the AOF, there remains a
requirement for Health Boards to prepare a Primary Care Annual Report (referred to
in this document as the Report).
The Information Set provides a range of primary care data to support LHB teams in
the development of their Report. However, it is not comprehensive and does not
restrict the use of information from other sources or presentation in alternative
formats.
The purpose of the Information Set is to:
•
raise the profile of important issues for consideration by the Board
•
provide comparative analysis for Board teams
•
indicate the need for action or opportunities to demonstrate progress
•
increase the use of routinely available information
3|Page
This is the second Information Set and Boards should assess whether
appropriate action has been taken and sufficient progress made, to address
the issues identified in the previous year’s Report.
Where there are outstanding or new issues identified, a clear plan (or set of
actions) for delivering improvement should be established.
Setting the Direction and Together for Health clearly identify the role for
Primary and Community Services as part of an integrated approach to health
care. Boards must to be assured this is being progressed appropriately to
meet the needs of the people within their area.
Research continues to identify the positive impact of high quality primary care
systems1. Whilst the innovative nature of independent contractor status has many
benefits, there is a need to ensure that patients and their families are offered
‘consistently good healthcare2’ and can be assured of appropriate standards of care
across all settings. The Report should bring together examples of the wide range of
work undertaken to support such services, demonstrating how the delivery of high
quality care is ensured. Reports should also demonstrate how individual initiatives
relate to key strategic objectives, improving both individual care and the coordination
of services.
The 2010 Reports provided Boards with detailed information with regard to the
structures and processes in primary care, with particular reference to General
Practitioner (GP) services. There were many examples of good practice and
innovation. It will be helpful for subsequent Reports to clearly describe the strategic
priorities, clarity of objectives and evidence of outcomes. The Information Set
provides comparative data and examples of analysis to support this work. LHB
teams should demonstrate more detailed local analyses, judgement and actions.
1
2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven
Countries.
2
Health Foundation (2010) http://www.health.org.uk/publications/evidence-in-brief-how-safe-are-
clinical-systems/
4|Page
Boards will then have sufficient detail to undertake appropriate scrutiny and provide
evidence of assurance to the public and Welsh Government.
The 2011/12 Information Set continues to provide a focus on GP services, since this
is where the majority of unscheduled medical care and chronic conditions
management is delivered. It is broadly consistent with the previous year’s
Information Set to enable year on year comparisons to be made. However, this
second document provides a widened range of information and ongoing work with
Health Board teams will seek to identify other useful sources. The 2011 Reports
must illustrate work that ensures local services are effective, responsive, coordinated
and demonstrate public engagement in service planning and the delivery of care.
Key Initiatives
Together for Health sets out the Five Year vision for the NHS in Wales. It refers to
strong local primary and community services available to everyone, wherever they
live. It also highlights the need to improve access to primary care services, develop
community based teams and deliver care closer to home.
http://wales.gov.uk/topics/health/publications/health/reports/together/?lang=en
Setting the Direction is the Primary & Community Services Strategic Delivery
Programme. The document sets out a framework to assist LHBs in the development
and delivery of improved primary care and community based services for their local
populations; particularly for those individuals who are frail, vulnerable and who have
complex care needs.
http://wales.gov.uk/docs/dhss/publications/100727settingthedirectionen.pdf
High Impact Service Changes are key areas of service redesign for chronic
conditions, identified as priorities for their potential to raise the quality of patient
services and to make efficiency savings.
http://wales.gov.uk/docs/dhss/publications/110216changesen.pdf
5|Page
1000 Lives Plus is a national programme which seeks to improve the quality of
patient care and reduce avoidable harm across NHS Wales.
In Primary Care there are a number of work streams: •
Chronic Heart Failure
•
Monitoring of anti coagulation
•
Atrial Fibrillation
http://www.wales.nhs.uk/sites3/home.cfm?orgid=781
The Quality and Outcomes Framework (QOF) is an annual incentive programme
that rewards GP practices for high quality service in the following areas:•
Common chronic diseases
•
Practice organisation
•
Patient experience
•
Additional services such as child health and maternity
The QOF process provides a wide range of comparative data that can be used to
identify opportunities for service improvement.
http://www.wales.nhs.uk/sites3/page.cfm?orgid=480&pid=6063
QOF Quality and Productivity. In 2011, eleven quality and productivity (QP)
indicators were introduced. These aim to secure more effective use of NHS
resources through improvements in the quality of primary care, by rewarding more
clinically and cost-effective prescribing, reducing emergency admissions by providing
care to patients through the use of alternative care pathways and reducing hospital
outpatient referrals.
www.wales.nhs.uk/sites3/docopen.cfm?orgid=480&id=171844
6|Page
Enhanced Services add to essential services or deliver higher than specified
standards, with the aim of increasing the delivery of care in the community setting
and reducing demand on secondary care. Enhanced services expand the range of
services to meet local need, improve convenience and extend choice.
http://www.wales.nhs.uk/sites3/page.cfm?orgid=480&pid=6064
Assurance. Health Boards must have effective arrangements in place to confirm:
•
Correct and valid payment to service providers
•
Quality assurance of service providers’ self declaration of delivery
•
Assessment of effectiveness and efficiency of service delivery
•
Consideration of improvements in the effectiveness and efficiency in the
delivery of services
Boards have a duty to protect patients from poor performance, to support
underperforming practices to improve and to share good practice. Assurance
processes should evidence work across the spectrum of practice quality.
7|Page
Equity
GP practices provide the gateway to most NHS services and strong primary care
provision contributes to the effective and efficient use of health care resources
(Starfield, 2009). Socio economically deprived communities have increased health
care needs and show widening gaps in life expectancy between the least and most
deprived groups3.
It is therefore important that:
"At a minimum the health service should ensure that disadvantaged groups have
equal access to NHS services". 4
Workforce
Boards must have clear primary and community service development plans which
specify sufficient detail of the delivery of care to inform an understanding of the
requirement for estate and workforce development. This will include some analysis
of roles and responsibilities in new models of care, to inform nursing, medical and
other workforce development issues. This work should include the contribution of
primary care independent contractors and their teams.
The following presents a summary of workforce data relating to General Medical
Practitioners (GPs) in Wales.
3
Chief Medical Officer for Wales Annual Report 2010
4
Marmot Review Economic Framework Report, 2009
8|Page
Total GP numbers by age
3000
Under 30
2750
30-44
45-54
55-64
65 and over
2500
2250
Number
2000
1,936
1,940
1,940
1,989
2009
2010
1750
1500
1250
1000
750
500
250
`
0
2007
2008
Source: ‘GMS Census, General Medical Practitioners, 2000-2010’
This summary does not include the contribution of locum staff as the data is not
collected routinely. More information on GP workforce statistics can be found in the
General Medical Practitioners, 2000-2010 Statistics Release.
Despite the strategic priorities of better GP access, earlier diagnosis and proactive
management of chronic conditions and greater delivery of care in the community
setting, GP numbers do not show significant change. Boards will need detailed local
analysis and should also consider the impact of increases in part time working,
retirements and an increasing demand for GP skills in a variety of settings, including
accident and emergency departments and outpatient clinics. The analysis of GP
workforce should include out of hours services.
The provision of District Nurses also shows no evidence of increased capacity, with
decreasing numbers in some areas.
9|Page
Whole Time Equivalent (WTE) – District Nurses
Source: Electronic Staff Record (ESR)
Snap shot as at 31 March 2010 and 2011
The development of Community Resource Teams should create additional capacity
but this may not be captured in the core District Nurse data.
Workforce Plans should be based on analysis of health need and a clearly
described service model.
Boards should consider the full provision of staff in the community model and
understand the availability of services at night, weekends and Bank Holidays
to support patients in their own homes.
This work should also demonstrate how resources are moving to support
more proactive management and delivery of care in the community setting.
10 | P a g e
GP Practice Organisation
The quality of practice organisation is a key contributor to safety, patient confidence
and satisfaction. The Quality and Outcomes Framework Organisational Domain
provides a measure of GP practice performance in this area. Maximum achievement
for 2009/10 and 2010/11 was 167.5 points.
Distribution of total points achieved in the organisational domain by practices,
2009-10 and 2010-11
180
Total Organisational Points
160
140
120
100
80
60
40
20
0
2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11
Wales
Betsi Cadwaladr
ULHB
Powys Teaching
LHB
Hywel Dda LHB
ABM ULHB
Cwm Taf LHB
Aneurin Bevan
LHB
Cardiff & Vale
ULHB
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
This chart is a box plot and has the following features;
•
The box in blue at the centre shows the range of points achieved by the
middle 50 percent of practices
•
The line within the box, shows the median (middle value) in the range of
practice points achieved
•
The bars extending above and below these boxes show the full extent of the
range of points achieved, seen in the other 50 percent of practices.
11 | P a g e
The graph shows a high level of performance for most practices, with an average of
more than 160 points at an all Wales level. In LHBs such as Hywel Dda and Cardiff
and Vale there has been an improvement in the achievement of the lowest
performing practices, indicating more consistent standards across the LHB area.
There remain a number of practices that achieve much lower performance than
their peers and Boards should ensure the reasons for that performance are
understood and action taken where appropriate.
Clinical Indicators
QOF promotes the use of evidence-based medicine but allows flexibility for clinical
judgement and patient choice through exception reporting. Some exception reporting
is applied automatically by the GP clinical system, for example in respect of patients
who are recently registered with a practice, or who are recently diagnosed with a
condition. In such cases these exceptions are termed ‘exclusions’. Other exception
reporting is based on information entered into the clinical system by the GP practice.
For example, where a patient has declined treatment, is unsuitable for treatment or is
on the maximum tolerated dose of a drug, a GP practice can enter an appropriate
Read code to ‘except’ the patient from the appropriate QOF indicator.
Some
variation is to be expected but unusually high rates of exceptions may indicate
inequity.
Boards should ensure there is a robust quality assurance framework in place
to confirm the appropriateness of such decisions, to ensure that vulnerable
patients are not removed from target Registers before significant efforts have
been made to achieve good outcomes.
12 | P a g e
Effectiveness
The following table shows the steady rise in reported disease and risk factor
prevalence rates in most QOF clinical areas, illustrating an increasing workload for
primary care teams.
All-Wales QOF - Reported Disease Prevalence Rates
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
Other data sources may also be relevant to local analysis, whilst taking full account
of the different methodologies which may be utilised. For example, the Welsh Health
Survey records the percentage of adults who report being treated for high blood
pressure, with a Wales average of 20% and a range from 16% to 25%. Whilst such
sources will vary due to differing methodology the difference from the recorded QOF
prevalence suggests the potential for unmet need, particularly where differences are
extreme. QOF quality assurance processes should include reviews of case finding
approaches where appropriate.
13 | P a g e
To ensure that all patients with, or at risk of chronic conditions are offered
appropriate advice, investigation, treatment, and a jointly agreed care plan is
recorded.
Boards should understand gaps between expected and actual
numbers on all registers.
QOF provides information in relation to a wide range of clinical indicators, providing
one method for measuring and evaluating the consistency of clinical care delivery.
The following chart shows the summary of performance against the whole clinical
domain in QOF (maximum achievement 697 points), demonstrating high levels of
performance overall. Variation between practices has reduced at an all Wales level,
in Cardiff and Vale, Betsi Cadwaladr, Cwm Taf and Powys, but in Aneurin Bevan,
variation has increased.
Distribution of Total Points achieved in the clinical domain by practices,
2009-10 and 2010-11
700
Total Clinical Points
600
500
400
300
200
100
0
2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11
Wales
Betsi Cadwaladr
ULHB
Powys Teaching
LHB
Hywel Dda LHB
ABM ULHB
Cwm Taf LHB
Aneurin Bevan
LHB
Cardiff & Vale
ULHB
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
14 | P a g e
Hypertension
The early identification and effective management of hypertension plays a key role in
the prevention of cardiovascular disease. Boards must ensure that patients are
provided with opportunities to assess their need and consider available interventions.
The chart below shows there has been an increase in the mean aggregated crude
GP practice prevalence from 2007 to 2011.
Mean Health Board crude QOF prevalence growth 2007-2011 Hypertension
Pow
Crude prevalence per 1000 patients
170
CwmTaf
AB
BCU
160
HywelDda
150
ABMU
140
130
CV
120
110
100
2007
2008
2009
2010
2011
AB = Aneurin Bevan ; ABMU = Abertawe Bro Morgannwg; BCU = Betsi Cadwaladr ; CV = Cardiff & Vale ; Pow= Powys
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
Boards should seek assurance that practices have appropriate case finding
strategies in place and be able to evidence that appropriate support or
sanctions have been applied where necessary.
Increasing prevalence may result from a combination of improved case finding and
advances in data quality. The Audit + product, which is available to all practices in
Wales, provides “tidy up” searches of clinical systems to identify patients who do not
have a formal diagnosis recorded but may be receiving treatment.
15 | P a g e
The chart below demonstrates the variation in individual GP practice prevalence by
Health Board for the two years 2009/10 and 2010/11.
Variation in Health Board GP practice QOF prevalence 2009/10 and 2010/11
Crude Prevalence /1000 registered patients
Hypertension
Hypertension
300
250
200
150
100
50
0
Aneurin
Bevan
Aneurin
Bevan
ABM U
ABM U
2010
2011
2010
2011
Betsi
Betsi Cardiff & Cardiff & CwmTaf CwmTaf Hywel DdaHywel Dda Powys
Powys
Cadwaladr Cadwaladr Vale U
Vale U
Teaching Teaching
U
U
2010
2011
2010
2011
2010
2011
2010
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
2011
2010
2011
Wales
Wales
2010
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
This chart demonstrates no significant change in prevalence between the two years
at an all Wales level. Proactive case finding to improve equity and support key
initiatives such as the stroke risk reduction strategy would cause movement of the
whole group i.e. box, median and range of prevalence upwards . More detailed local
analysis will highlight where improvements have been achieved and identify where
further work is required. Records of zero prevalence suggest data quality issues
which should be addressed.
Boards should seek assurance that the variation has been identified, explored
and can be explained.
16 | P a g e
Management of hypertension
Boards should be assured that evidence based interventions described by the QOF
are maximised for patients on disease registers, where appropriate. For
hypertension there are two interventions, Indicators BP04 and BP05: BP04- “The percentage of patients with hypertension in whom there is a record of
the blood pressure in the previous 9 months”
BP05- “The percentage of patients with hypertension in whom the last blood
pressure (measured in the previous 9 months) is 150/90 or less”
The chart below shows the range of individual GP practice achievement for ensuring
that patients with identified hypertension have received a recent review of their blood
pressure
Variation in Health Board GP practice QOF indicator coverage 2010-11 BP04
BP measurement & recording
percentage of patients recorded
100
95
90
85
80
75
70
Wales
Wales
2010
2011
Abertawe Abertawe
BMU
BMU
2010
2011
Aneurin
Bevan
2010
Aneurin
Betsi
Betsi
Cardiff & Cardiff & Cwm Taf Cwm Taf Hywel DdaHywel Dda Powys
Bevan Cadwaladr Cadwaladr Vale
Vale
2011
2010
2011
2010
2011
2010
2011
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
2010
2011
2010
Powys
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
Each pair of bars represents one Health Board, the median performance for the
Board and the change in range of practice achievement from 2009/10 to 2010/11.
Some Boards have achieved a reduction in the most extreme variation but there
remain significant differences. In some cases there is increasing variation.
17 | P a g e
Whilst the blood pressure target of 150/90 will not be appropriate for all patients, and
some may choose to decline treatment, overall measures of performance indicate
the delivery of evidence based approaches at a population level.
The achievement of treatment to target across Wales in the chart below shows
improvement from a median of 79.6 per cent in 2009-10 to 80.7 per cent in 2010-11.
The median underlying achievement for BP05 rose in every LHB in that period.
Variation in Health Board GP practice QOF indicator coverage 2010-11 BP05
BP managed to target
percentage of patients recorded
100
90
80
70
60
50
40
Wales
Wales
2010
2011
Abertawe Abertawe
BMU
BMU
2010
2011
Aneurin
Bevan
2010
Aneurin
Betsi
Betsi
Cardiff & Cardiff & Cwm Taf Cwm Taf Hywel DdaHywel Dda Powys
Bevan Cadwaladr Cadwaladr Vale
Vale
2011
2010
2011
2010
2011
2010
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
2011
2010
2011
2010
Powys
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
However, the range of practice achievement within each LHB was slightly greater in
2010-11 than 2009-10. Aneurin Bevan LHB had the widest range of underlying
achievement in 2010-11 from 57.1 per cent to 100.0 per cent.
Boards should seek assurance that actions detailed within their 2010/11 report
have been progressed. Additionally, reasons for any enduring or new
variations should be understood and action taken where appropriate.
18 | P a g e
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease remains a leading cause of disability,
emergency hospital admission, readmission and mortality. It also contributes to the
life expectancy gap between the least and most affluent and contributes significantly
to sickness absence. There is a need to improve case finding approaches and
diagnostic accuracy since many cases remain undiagnosed or misdiagnosed.
The High Impact Service Change work identifies a number of indicators of successful
impact to improve care:
•
Patients are diagnosed and treated at an earlier stage of disease
•
Treatments in primary care, especially prescribing, are appropriate and cost
effective
•
Referrals to specialists are more appropriate, timely and focused, especially
for those patients with complex or resistant disease
•
GP audits of their diagnostic accuracy rates
Link to High Impact Service Change document:
http://wales.gov.uk/topics/health/nhswales/healthstrategy/ccm/ccmdocuments/chang
es/?lang=en
LHBs can work to improve early diagnosis by considering estimates of local
prevalence to identify the potential for unmet need. GP practice data can then be
used to review performance and work towards identifying undiagnosed patients.
QOF COPD registers provide an estimate of prevalence and unusually low or high
levels should be reviewed. The mean aggregated GP practice QOF prevalence is
stable from 2007 through to 2011 despite the priority given to earlier diagnosis.
There is variation in individual GP practice prevalence which is demonstrated by the
box plot shown in the chart overleaf. Each pair of bars represents one Health
Board’s range of individual practice prevalence rates over the two year period
2009/10 and 2010/11.
19 | P a g e
Crude Prevalence /1000 registered patients
Variation in Health Board GP practice QOF prevalence 2010-11 COPD
COPD
100
90
80
70
60
50
40
30
20
10
0
Aneurin
Bevan
Aneurin
Bevan
2010
2011
Abertawe Abertawe
Betsi
Betsi
Cardiff &
BMU
BMU Cadwaladr Cadwaladr
Vale
2010
2011
2010
2011
2010
Cardiff &
Vale
CwmTaf
2011
2010
CwmTaf Hywel DdaHywel Dda
2011
2010
2011
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
Powys
Powys
Wales
Wales
2010
2011
2010
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
There has been little change in the variation of prevalence between the two years.
Boards should be assured that variation has been explored and addressed. In
order to ensure that all patients with disease or at risk are offered appropriate
advice, investigation and treatment, Boards should consider the use of
prevalence modelling to identify gaps between expected and actual numbers
on all registers.
Once cases are identified, the Board will wish to be assured that evidence based
interventions are offered to all patients on the QOF disease register, where
appropriate. Within the COPD domain of the QOF there are four identified
interventions. This report will look at two:
•
COPD 10. The percentage of patients with COPD with a record of
FeV1(Forced expiratory volume in 1 second) in the previous 15 months. This
is a measure of the severity of the patient’s condition. Regular monitoring will
identify patients with increasing severity of disease who may benefit from
medication review or referral for specialist advice and treatment.
•
COPD 8. The percentage of patients with COPD who have had influenza
immunisation in the preceding 1 September to 31 March
20 | P a g e
The following charts shows the range of individual GP practice percentage coverage
of the entire QOF COPD register for the QOF interventions described above. Each
pair of bars represents one Health Board and the change in range in coverage from
2009/10 to 2010/11.
Variation in Health Board GP practice QOF indicator coverage 2010-11
COPD10 – Measurement of severity (record of FeV1)
100
percentage of patients recorded
90
80
70
60
50
40
30
20
10
0
Wales
Wales
2010
2011
Abertawe Abertawe
BMU
BMU
2010
2011
Aneurin
Bevan
2010
Aneurin
Betsi
Betsi
Cardiff &
Bevan Cadwaladr Cadwaladr
Vale
2011
2010
2011
2010
Cardiff & Cwm Taf Cwm Taf Hywel DdaHywel Dda Powys
Vale
2011
2010
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
2011
2010
2011
2010
Powys
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
The extreme variation of this indicator suggests that data quality issues should be
considered and addressed where necessary. Boards will wish to ensure that
accurate data is available to support quality assurance of services and to identify
areas for service improvement. This is a key clinical area for the development of
planned care and reduction of unscheduled hospital admission.
COPD 08- Flu immunisation for patients with COPD.
Flu immunisation for patients with chronic diseases is a key aspect of preventive
care. Data from the Quality and Outcomes Framework suggests coverage of over
90% of the population of patients with COPD. The Chronic Obstructive Pulmonary
Disease indicator, COPD08, is defined as “The percentage of patients with COPD
who have had influenza immunisation in the preceding 1 September to 31 March”.
21 | P a g e
The chart below demonstrates the varying range in individual practice coverage for
2010 and 2011. This represents coverage for the whole Register of COPD patients,
regardless of exception reporting. This presentation provides a clear picture of the
contribution of GP practice immunisation programmes to the Public Health
programme.
Variation in Health Board GP practice QOF indicator coverage 2010-11
COPD08 – Flu Immunisation
100
percentage of patients recorded
90
80
70
60
50
40
30
20
10
0
Wales
Wales
2010
2011
Abertawe Abertawe
BMU
BMU
2010
2011
Aneurin
Bevan
2010
Aneurin
Betsi
Betsi
Cardiff & Cardiff & Cwm Taf Cwm Taf Hywel DdaHywel Dda Powys
Bevan Cadwaladr Cadwaladr Vale
Vale
2011
2010
2011
2010
2011
2010
2011
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
2010
2011
2010
Powys
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
Rates of exception reporting for this indicator remain extremely variable. The chart
overleaf demonstrates this showing the range of individual GP practice exception
rates over the two years by Health Board.
22 | P a g e
Variation in Health Board GP practice QOF exceptions 2010-11 COPD08 – Flu
percentage of patients excepted by the practice
exceptions
50
45
40
35
30
25
20
15
10
5
0
Wales
Wales
2010
2011
Abertawe Abertawe
BMU
BMU
2010
2011
Aneurin
Bevan
2010
Aneurin
Betsi
Betsi
Cardiff &
Bevan Cadwaladr Cadwaladr
Vale
2011
2010
2011
Cardiff & Cwm Taf Cwm Taf Hywel DdaHywel Dda Powys
Vale
2010
2011
2010
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
2011
2010
2011
2010
Powys
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
Boards should ensure that:
The QOF evidence based interventions, such as immunisation, are offered
to all patients on the respective QOF registers.
Variation in clinical practice is analysed and action agreed where
necessary.
Consideration is given to the difference in the QOF target coverage and the
coverage of the entire QOF register.
Exception reporting is reviewed as a key aspect of the QOF quality
assurance process.
23 | P a g e
Diabetes
Since 2000, the number of people with diabetes has doubled worldwide. High levels
of obesity in Wales create a particular risk and medical approaches alone are
unlikely to provide a solution to this problem. However, health services do have a
role to play to offer evidence based interventions, to manage diabetes and its
complications, to reduce the risks of cardiovascular events, blindness and renal
failure. Health Boards have responsibility for ensuring consistent, high quality of
care. Evidence that early identification is improving can be estimated by increasing
prevalence as measured by QOF Diabetes registers. The chart below shows the
mean growth in the QOF prevalence in each health board.
Mean Health Board QOF crude prevalence growth 2007-11 - Diabetes
Crude prevalence per 1000 patients
60
Diabetes
AB
ABMU
55
HywelDda
CwmTaf
Pow
50
BCU
45
CV
40
35
30
2007
2008
2009
2010
2011
AB = Aneurin Bevan ; ABMU = Abertawe Bro Morgannwg; BCU = Betsi Cadwaladr ; CV = Cardiff & Vale ; Pow= Powys
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
24 | P a g e
Variation at a practice level, as recorded in the QOF Diabetes Registers is illustrated
in the chart below.
Crude Prevalence /1000 registered patients
Variation in Health Board GP practice QOF prevalence 2010-11 - Diabetes
Diabetes
100
90
80
70
60
50
40
30
20
10
0
Aneurin
Bevan
Aneurin
Bevan
2010
2011
Abertawe Abertawe
Betsi
Betsi
Cardiff & Cardiff &
BMU
BMU Cadwaladr Cadwaladr Vale
Vale
2010
2011
2010
2011
2010
2011
CwmTaf
2010
CwmTaf Hywel DdaHywel Dda Powys
2011
2010
Please note: 2010 and 2011 relates to financial years 2009/10 and 2010/11 respectively
2011
2010
Powys
Wales
Wales
2011
2010
2011
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
The variation in individual practice prevalence shows little change over the two
years.
Prevalence modelling suggests where there may be a gap between identified cases
and the complete population need. In the case of diabetes, Public Health Wales has
used the Association of Public Health Observatory (APHO) tool to estimate the
prevalence of diabetes. The chart below shows this applied to the former LHB
populations in 2010. The blue column shows the modelled, estimated prevalence,
with the white dot showing the QOF rate. The APHO model provides an estimate
with a confidence range.
Link: http://www.apho.org.uk/resource/item.aspx?RID=95482
25 | P a g e
Modelled data (2010) with confidence intervals shown v actual QOF registers
2010 Welsh Local Authorities
Source: Public Health Wales Observatory
This suggests that there may be a gap between cases identified through QOF and
the “real” prevalence indicating some unmet need.
Boards should be assured that:
Local modelling is undertaken as an estimate of need. Measured prevalence
should be tested against such models and differences understood.
Where unmet need is suspected, case finding strategies should be reviewed.
Workload implications are understood and addressed.
26 | P a g e
Timeliness
GP Access
Improved access to GP services remains a key Government commitment,
particularly for groups that have raised concerns that their reasonable needs are not
being met.
LHBs are responsible for ensuring that local needs are assessed and appropriate
services developed. The assessment of reasonable need and appropriate provision
of service is complex and requires a proactive approach to patient and public
engagement with regular feedback of compliments and concerns to inform further
developments. Community Health Councils and Patient Participation Groups may
offer particularly valuable contributions to that work. Boards must ensure that such
work has a high priority with clear actions and regular monitoring of progress to
ensure effective delivery.
The QOF Welsh GP Patient Access Survey, 2011 provides patient feedback in
relation to 24 hour access and ability to book ahead.
http://wales.gov.uk/docs/statistics/2011/110616sdr1032011en.pdf
Just over 99,000 completed questionnaires were received from 483 GP surgeries
across Wales. Overall, 93% of patients reported that they had tried to see or speak
to a GP or healthcare professional on the same day or the next day the GP surgery
or health centre was open. Of those who had tried to see or speak to a GP or
healthcare professional fairly quickly, the majority (84%) reported that they were able
to do so.
A total of 90% of patients said that they had tried to book ahead (more than two full
days in advance) for an appointment with a GP or healthcare professional. Of these,
74% said they were able to book in advance the last time they tried to do so.
27 | P a g e
Ability to book appointments in advance by Local Health Board
Source: GP Access Survey
Link to data: GP Access Survey, 2011
In total, 80% of patients reported that they found it either ‘very easy’ or ‘fairly easy’ to
get through to their doctor’s surgery on the phone.
Overall, 92% of patients reported that they were either ‘very satisfied’ or ‘fairly
satisfied’ with the care they had received at their surgery, including 66 per cent who
were very satisfied. 3% of patients expressed dissatisfaction.
There are currently no routine publications available on GP opening hours but an
article is scheduled for publication by the Welsh Government. Please note this is
management information and the data reported is by Health Boards. Data recorded
by Health Boards suggests there remain significant differences between practices in
relation to opening hours.
28 | P a g e
Percentage of surgeries with half-day closing, by Local Health Board
Please note: 2010 and 2011 refer to calendar years.
Source: Welsh Government
In most LHBs half day closing is reducing, reflecting the advice of GPC Wales
(add link to GPC letter here)
GP ‘In hours’ services cover from 8am to 6.30pm, Monday to Friday with all other
times managed by the Out of Hours services. Whilst there is considerable variation
between LHBs in relation to the proportion of the ‘contracted hours’ that practices are
open for patients to attend, in most areas access is improving.
Percentage of surgeries opened for 95% or more of their contracted weekly
hours, by Local Health Board
Source: Welsh Government
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The table below illustrates improvements to access between 2010 and 2011.
2010
(Percentage of weekly contracted hours)
Local health board
90% or more
95% or more
Abertawe Bro Morgannwg
Aneurin Bevan
Betsi Cadwaladr
Cardiff and Vale
Cwm Taf
Hywel Dda
Powys
71%
55%
54%
59%
21%
60%
88%
51%
37%
29%
44%
8%
36%
65%
Wales
56%
36%
100% or
more
2011
(Percentage of weekly contracted hours)
100% or
more
90% or more
95% or more
35%
17%
14%
18%
0%
27%
24%
68%
73%
62%
62%
35%
65%
88%
42%
54%
30%
43%
18%
45%
65%
34%
29%
16%
28%
6%
36%
24%
19%
63%
40%
25%
Source: Welsh Government
Boards should:
•
Demonstrate a clear understanding of local access needs.
•
Have clear plans in place to address concerns.
•
Review progress regularly and be able to demonstrate improvement.
•
Patient experience must be a key driver for service improvement.
30 | P a g e
Efficiency
The Quality and Outcomes Framework was revised in 2011 to include eleven Quality
and Productivity (QP) indicators. This approach sought to secure improvements in
the quality of primary care and more effective use of NHS resources by rewarding
more clinically and cost-effective prescribing, reducing emergency admissions by
providing care to patients through the use of alternative care pathways and reducing
hospital outpatient referrals due to inefficient and/or ineffective processes.
Together for Health continues to encourage integration that enables support for this
type of improvement work, removing waste and adding value. A simple example of
this might be the removal of medicines that were no longer required by a patient on
repeat prescriptions, or perhaps the ‘switching’ or exchanging of a high cost branded
drug for a low cost generic drug with no negative clinical impact on the patient.
Health Board localities/networks have been established to reflect local populations of
between 30,000 and 50,000 people Clusters of GP practices have met to review
prescribing, referrals and emergency admissions, identifying opportunities for service
improvement and more efficient use of resources.. The specification of the QOF QP
indicators requires professional, collaborative and meaningful reflection; evidenced
through summary reports of internal and external reviews. These findings should
contribute to agreements/action plans supported and facilitated by the Boards.
Prescribing work should build upon the strong history of analysis and peer review
that has proved effective at managing costs across a range of clinical areas. For
example, more consistent use of low cost statins has potential to deliver over
£6million in savings.
31 | P a g e
Simvastatin and Pravastatin as % of all Statins (Including ezetimibe
combination products) July-September 2011.
Source: Prescribing Services Website
Diabetic Monitoring Cost per 1000 PU’s Weighted by Prevalence JulySeptember 2011
Source: Prescribing Services Website
32 | P a g e
Agreed approaches to diabetic monitoring could achieve more consistent
management and reduce the variation in costs shown above.
•
Boards should assure themselves that they are effectively supporting,
managing and developing locality networks to ensure that GPs and their
teams are able to contribute to service modernization and the most
effective and efficient use of resources.
•
Boards should ensure that processes are in place to capture the
learning from Locality reports and action recommendations where
appropriate.
•
Boards should understand the potential of such approaches and have
mechanisms in place to assure delivery.
•
Board Reports should summarise the impact of QOF QP upon
prescribing costs and quality improvement.
33 | P a g e
Patient experience
QOF provides one measure of patient experience. The summary of indicators
includes length of consultations, access within 24 hours and ability to book an
appointment more than 2 days ahead. This data was obtained from the GP Access
Survey undertaken over a two week period in February 2011.
Distribution of Total Points achieved in the Patient Experience domain by
practices, 2009-10 and 2010-11.
Total Patient Experience Points
100
80
60
40
20
0
2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11 2009-10 2010-11
Wales
Betsi Cadwaladr
ULHB
Powys Teaching
LHB
Hywel Dda LHB
ABM ULHB
Cwm Taf LHB
Aneurin Bevan
LHB
Cardiff & Vale
ULHB
Source: CM Web
Link to data: General Medical Services Contract: Quality and Outcomes Framework
Statistics, 2010-11
Whilst patient experience is generally positive, there is wide variation at practice
level. Boards must demonstrate the actions that it has undertaken to address
relevant issues in practices where reported experience is poorest.
Some GP practices have developed Patient Participation Groups, in order to
understand the needs of local people and to use their experience and ideas to
improve the delivery of care. Practices and LHBs may also find the Community
Health Councils a useful source of advice.
34 | P a g e
As the QOF patient experience survey will not be repeated, Boards will wish to
consider how they will continue to capture the views of patients and the public using
the new National Survey for Wales and other sources.
http://wales.gov.uk/about/aboutresearch/social/ocsropage/nationalsurveyforw
ales/?lang=en
35 | P a g e
Complaints
There is a rising trend in complaints about Family Health Services. For year ending
31 March 2011 there were 3,793 complaints, an increase of 7% on the previous
year.
Total Complaints
Source: KO41 return forms
Link to data: Complaints to the NHS, 2010-11
FHS complaints by LHB, year ended 31 March
Source: KO41 return forms
Link to data: Complaints to the NHS, 2010-11
The chart above shows a rising trend in complaints in Betsi Cadwaladr, Aneurin
Bevan and Hywel Dda Local Health Boards.
36 | P a g e
Complaints about General Practitioners rose by 12% and about General Dental
Practitioners by 1%5.
Complaints about Family Health Services (FHS) are collected from Local Health
Boards (LHBs). As not all of the General Medical Practitioners (GMPs) and General
Dental Practitioners (GDPs) submit details of the number of complaints received by
them to their LHB, the numbers shown in the previous charts, may underestimate the
number of complaints made about Family Health Services. Increased efforts by
LHBs to collect the data in 2009-2010 are likely to have affected the rise in the total
number of complaints.
Boards should be assured of the engagement of patients in the planning and
delivery of care. Patient experience should be a key driver for quality
improvement and services development initiatives.
5
KO41 return forms Complaints to the NHS, 2010-11
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Safety
LHBs must ensure that Primary Care contractors have robust systems of
governance. The All Wales Clinical Governance Self Assessment Toolkit
(AWCGSAT) is designed to encourage general practices to reflect and assess the
governance systems they have in place in order to facilitate the delivery of safe and
effective clinical practice. The Public Health Wales Primary Care Quality and
Information Service (PHW PCQUIS) developed tool is designed to measure
improvement over time i.e. from 2010-13 with a recommendation for three phases of
completion. For 2010/11 practices were encouraged to begin a regular process of
reflection, working as a team to consider the following 11 areas:
•
Availability of consultations
•
Equity of Access
•
Consent for clinical examination and treatment
•
Chaperone
•
Safeguarding Children
•
Waste Management
•
Infection Control
•
Patient Safety alerts and reporting
•
Communication systems
•
Risk Assessment
•
Raising concerns
For 2011/12, practices are asked to consider a further 20 areas and to review
progress on the 11 areas above, with the remaining areas and review of the first two
tranches to be considered in 2012/13. More information can be obtained from the
PHW PCQUIS intranet webpage.
http://howis.wales.nhs.uk/sitesplus/888/page/37945.
38 | P a g e
In July 2011, LHBs were provided feedback on the 11 areas outlined above. The
chart below shows how many practices engaged with the AWCGSAT during 2010/11
by Health Board.
Source: Clinical Governance Practice Self Assessment Tool
Not all Health Boards are following the suggested completion schedule and have
developed processes to meet local need.
The chart below shows the picture at the Wales level with counts of practices at each
level of maturity over the 11 areas outlined for 2010/11.
39 | P a g e
Clinical Governance Tool 2010/11 (Wales @ 31/07/11)
Number of Practices @ Each Maturity Level (Initial 11 Questions)
Not Answered
Level 0
Level 1
Level 2
Level 3
Level 4
Level 5
100%
33
33
28
32
46
70%
69
56
69
22
23
30
22
21
35
41
45
40
12
11
12
14
18
0
10
1
15
23.1a RAISING
CONCERNS
0
1
40
23
1
9
22.1a RISK
ASSESSMENT
7
3
0
10
17.1a
COMMUNICATION
SYSTEMS
36
14.1a PATIENT
SAFETY ALERTS
AND REPORTING
3.1a EQUITY OF
ACCESS
63
46
13.1a WASTE
MANAGEMENT
2.1a
AVAILABILITY OF
CONSULTATIONS
6
4
32
10.1a
SAFEGUARDING
CHILDREN
0
4
5.1a
CHAPERONE
13
0
74
56
4.1a CONSENT
FOR CLINICAL
EXAMINATION
AND TREATMENT
39
30
62
69
47
35
46
42
45
64
47
96
44
23
56
54
44
10%
0%
30
29
6
61
30%
20%
49
62
58
50%
40%
27
15
80%
60%
25
60
13.2a
INFECTION
CONTROL
90%
Source: Clinical Governance Practice Self Assessment Tool
The chart below is an area specific comparison between Health Boards, relating to
safeguarding children. The graph is annotated with the number of practices
completing the toolkit questions for each section.
10.1a SAFEGUARDING CHILDREN
Not answered
100%
90%
7
1
Level 1
Level 2
Level 3
Level 4
1
7
4
10
1
28
3
1
50%
4
40%
14
2
0%
9
6
3
6
24
10
20%
10%
3
1
70%
30%
Level 5
9
24
80%
60%
Level 0
2
1
1
27
1
3
Aneurin Bevan Abertawe Bro
Betsi
Cardiff and Cwm Taf LHB
LHB
Morgannwg
Cadwaladr
Vale
University LHB University LHB University LHB
4
3
Hywel Dda
LHB
Powys LHB
Source: Clinical Governance Practice Self Assessment Tool
40 | P a g e
Key messages:
•
The AWCGSAT is an approach, developed in Wales, to structure an
assessment of clinical governance arrangements
•
Use of the tool is not prescribed but Boards must seek evidence from
contractors to confirm that appropriate systems of governance are
established.
•
Practices shall, at the request of the Local Health Board, produce any
information which is reasonably required in connection with the LHB functions
•
There is a suggested timetable for completion but this may be tailored to
meet local needs.
•
Boards are encouraged to engage with practices to promote the use of this
tool.
•
Boards are encouraged to share the summary Board reports with practices to
allow them to assess their own progress in the context of all practices.
Boards should use practice specific and comparative information to inform
local discussion and to improve services. Boards will also be able to identify
areas that may require additional input to allow practices to develop further
through sharing of good practice or provision of additional training support.
41 | P a g e
Annex 1: Sources
Chief Medical Officer for Wales Annual Report 2010
http://wales.gov.uk/topics/health/ocmo/publications/annual/report2010/?lang=en
Workforce
https://www.escholar.manchester.ac.uk/uk-ac-man-scw:1d32939
-
Putting GPs where they are needed: an overview of strategies to correct
misdistribution. (2005)
Health maps
http://www.infoandstats.wales.nhs.uk/page.cfm?orgid=869&pid=40976
United Kingdom Health Statistics, Edition 4
http://www.ons.gov.uk/ons/rel/ukhs/united-kingdom-health-statistics/2010/edition-4-2010.pdf
Health Statistics and Analysis Primary Care outputs (most recent publication)
General Practice:
– Welsh GP Access Survey, 2011
o Contract ended. Last publication in 2011.
– General Medical Practitioners, 2000-2010
– General Medical Services Contract: Quality and Outcomes Framework Statistics,
2010-11
– Prescriptions by General Medical Practitioners, 2010-11
Dentistry:
–
–
–
–
NHS Dental Services, 2010-11
NHS Dental Services, October-December 2010
NHS Dental Services, July-September 2010
Adult Dental Health Survey, 2009: Summary Report
o Produced and published by Information Centre (IC)
42 | P a g e
– Community Dental Services, 2009-10
Prescriptions:
– Prescriptions Dispensed in the Community, 2000 to 2010 and Prescription Cost
Analysis (PCA) Data
– Prescriptions by General Medical Practitioners, 2010-11
– Community Pharmacy Services, 2009-10
Ophthalmic:
– Ophthalmic Statistics, 2010-11
Other primary care publications by Welsh Government:
– The primary care information set report 2010
o The 2010 was the first year the report was published and focused mainly on
GPs and QOF data including QOF points, prevalence, GP referrals and
patient experience.
Complaints
– Complaints to the NHS, 2010-11
NHS Direct/OOH
– NHS Direct Wales Update, Quarter Ending June 2011
Other primary care publications by Information Centre (IC) which includes data
for Wales:
–
–
–
–
Dental Earnings and Expenses, England and Wales, 2009/10
Dental Working Hours England and Wales 2008/09 and 2009/10
GP Earnings and Expenses 2008/09 Final Report
Investment in General Practice 2003/04 to 2009/10 England, Wales, Northern
Ireland and Scotland
– General Ophthalmic Services: Workforce Statistics for England and Wales 31
December 2010
43 | P a g e
Annex 2: Glossary of Terms
AOF
Annual Operating Framework
AQF
Annual Quality Framework
APHO
Association of Public Health Observatory
AWCGSAT All Wales Clinical Governance Self Assessment Toolkit
BP
Blood Pressure – Hypertension
CHC
Community Health Council
COPD
Chronic obstructive pulmonary disease
CRT
Community Resource Team
DH
District Nurse
ESR
Electronic Staff Record
FHS
Family Health Services
GDPs
General Dental Practitioners
GMPs
General Medical Practitioners
GP
General Practitioner
GPC
General Practitioner Committee
LHB
Local Health Board
NHS
National Health Service
QOF
Quality and Outcomes Framework
QP
Quality and productivity
PCQUIS
Primary Care Quality and Information Service
PHW
Public Health Wales
PPG
Patient Participation Groups
WTE
Whole Time equivalent
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