How a quality improvement framework resulted in population health gains (part 1)

Despite exceptional achievements resulting from the quality improvement framework (QIF) there is still work to do write Professor Ruth Chambers, Dr Elizabeth Cottrell and Tracey Cox.

Professor Ruth Chambers: 'We need to improve detection of CKD and tackle exception reporting.' Picture: UNP

In 2009 a financially incentivised QIF programme was introduced in NHS Stoke on Trent for the 53 practices.

The aim was to improve population health and life expectancy through improved detection and management of long-term conditions, so minimising health inequalities. This was delivered at a practice-based level with payment for achieving desired standards, and individualised and face-to-face support for practices to move towards provision of exemplary care.

Population health gains

The most impressive achievements of QIF have been the population-wide health gains, between quarter four of 2008/9 with those in 2011/12. There are improvements in absolute proportions of patients whose disease control is within target, and also in the relative position of NHS Stoke on Trent compared with the other 16 PCT areas in the West Midlands.

In particular, there are significant improvements in cholesterol control for patients with CHD (<5mmol/l). Although, cholesterol management for CVD patients is not incentivised by QIF, there seems to be an effect of QIF on the overall cholesterol management of patients in NHS Stoke on Trent. We assume that a GP or practice nurse faced with a patient with raised cholesterol is unlikely to differentiate between one on a CHD register and one who is not, when discussing a management plan. There is probably dual registration among a significant proportion of CHD and CVD patients so the finding of significant improvement in cholesterol management is likely to be accounted for by improved quality driven by QIF rather than merely representing a natural trend.

Similar population improvements in disease management have been seen for BP control among patients with hypertension, CHD, CVD, diabetes and CKD. Not only have absolute proportions of patients with controlled BP increased, in all conditions except diabetes, the ranking of NHS Stoke on Trent among West Midlands areas has risen. 

Demonstrating a greater improvement in quality than that expected from a natural trend

Further evidence of the power of QIF in improving health management has been provided by analysis of epilepsy management, which has not been a focus of QIF. NHS Stoke on Trent ranked the lowest in the West Midlands in terms of seizure control in both 2009 and 2012 which reflects the absence of a drive to improve generally over this time period.

Identifying disease

Chronic diseases can only be appropriately managed if they’ve been detected and are subject to appropriate follow-up. So we need accurate and comprehensive disease registers and, critical to this, sensitive detection of disease among our patient population. QIF (building on QOF) incentivises practices to have chronic disease registration levels nearing those expected for that patient population, and ensuring registers are accurate. QIF has promoted case finding and as a result absolute numbers of patients have increased for our patient population of 270,000: COPD (+ 644), diabetes (+1,732), hypertension (+811), CVA/TIA (+346) and AF (+202). However prevalence rates of each disease have varied considerably. For example, COPD prevalence decreased in year one but has since increased yearly. This is likely to demonstrate improved accuracy of registration in year one followed by more robust and sensitive case finding in subsequent years. But this isn’t as clear for all diseases, for example, prevalence rates have dropped yearly for CKD. The extent to which this reduction can be accounted for by improved accuracy and the amount which this drop has been buffered by new cases found cannot be identified. However, the fact that there have been notable changes in prevalence rates for these diseases indicates that practices are actively addressing both the sensitivity and accuracy of disease detection which lays the foundation for future better quality care.

Wider improvements

The QIF programme is far reaching, with standards and required practice actions reaching across many clinical and organisational domains. Wider improvements have been seen since inception of QIF, from 6,011 additional patients having completed an AUDIT-C assessment through to 100% of practices having and following a policy for following up patients after hospital discharge. Addressing health inequalities and creating individualised management plans has been promoted through improved documentation of ethnicity (61% in 2009 to 92% in 2012) and self-management of disease. Currently two-thirds of practices have self-management plans for ≥70% patients with asthma and COPD.

Not there yet

Despite exceptional achievements resulting from QIF there is still work to do. We need to improve detection of CKD and tackle exception reporting. Practice nurse numbers have dropped so there are more patients per whole-time-equivalent nurse on average; so we need to encourage the contribution of practice nursing. Patient satisfaction levels have improved with some intensive mentoring with staff at a practice-level, but generally still fall lower than the national average so further work is still required.

By Professor Ruth Chambers (GP and clinical director of practice development and performance), Dr Elizabeth Cottrell (GP academic registrar Keele University) and Tracey Cox (primary care development and performance lead), – all NHS Stoke on Trent CCG.

Acknowledgements: Professor Zafar Iqbal, Director of Public Health NHS Stoke on Trent PCT

Next week: How to run an incentive-based quality improvement scheme to enhance health (part 2) 

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