We are all compelled to provide quality healthcare in general practice, and incentive-driven quality improvement has been familiar since the introduction of QOF in 2004. However, the utility and effectiveness of this approach remain contentious. Not least due to the ceiling effect of its benefits; once a target has been met, the motivation for further improvement and thus, subsequent change is reduced.
Introducing a quality improvement scheme
Stoke on Trent is an inner-city area with high levels of deprivation and high health needs, and in 2008/9 we reckoned that attainment of quality care by general practices was inadequate. Further measures were required to incentivise not just good, but excellent care. Therefore, we introduced a quality improvement framework (QIF) to improve the local population’s health and life expectancy and to find patients with long-term conditions who were undiagnosed. QIF has pragmatic, achievable, aspirational quality indicators that were developed to promote exemplary practice among local GP surgeries. According to achievement of desired targets, points are awarded. Practices are paid £225 per point (weighted to practice list size). To complement and improve upon QOF, we decided that QIF targets could not remain static. So, an annual review and amendment of the desired targets and thresholds is undertaken to build on quality already achieved and to prevent duplication of payments.
Support for practices
To join the QIF programme, practices have to meet a minimum set of standards. Those initially ineligible were given support to raise their level of service to subsequently join the scheme. Originally 48 out of 55 practices were entered; this has since increased to 51 of 53 practices in 2011/2. To reduce the risk of worsening health inequalities, eligible practices were paid, upfront, £2 per weighted patient each year to support staffing and system changes required to meet the targets.
Practices included in QIF are supported in an individualised, face-to-face way to promote excellence. Provision of practice development plans promote achievable, clear and step-by-step targets for improvement. Further, where particular areas of weakness are identified, targeted face-to-face support, mentoring and development are provided. For example, where five practices were found to have significantly higher levels of exception reporting, they were assessed and their use reviewed. Where changes could be made, this was highlighted on an individual practice report which cited, patient-by-patient, inappropriate exception reports and provided alternatives or solutions such as free text explanations against the use of the code used.
Motivation through comparison
Practices receive annual feedback comparing their attainment of QIF standards with others. This informs practices on their current status and increases their motivation as, anecdotally, it has been noted that many GPs take a competitive approach to their relative position.
Realistic expectations to promote reduction in inequality
QIF recognises that the baseline level of service is different across the locality. Therefore, financial reward is not strictly set for attainment of absolute targets, but also significant improvements towards desired standards as appropriate.
QIF has an integrated educational programme to support changes in practice through improved knowledge/professional behaviour change. We have provided a variety of learning and development: including best practice resources for key conditions (eg atrial fibrillation, chronic heart failure, asthma, COPD, hypertension, dementia and CKD), communication skills training for receptionists, mentoring schemes, and a vast range of upskilling workshops. Thus QIF has supported long-term improvements in care rather than just a standalone rapid reward system.
This individual, practice-based incentive and support programme has resulted in a notable improvement in quality according to population-wide health measures. Data from 2008/9 and 2011/12 demonstrates the achievements of QIF at a population level. For example, the proportion of patients on CHD registers with a cholesterol of <5mmol/l has improved from just above the West Midlands average to significantly higher than the upper control limits for the current year. Similar improvements have been seen for BP control among NHS Stoke on Trent patients with CHD, CVA, CKD and hypertension. Among patients with diabetes, BP control has not increased as significantly in proportion to the West Midlands, however there has been a rise of 10% in the proportion of these patients whose BP has been controlled since QIF began. In contrast, epilepsy management has not been a focus of the QIF programme and in both 2008/9 and 2011/2 reports, NHS Stoke on Trent falls significantly below average with no notable improvement in actual or relative disease control.
Significant practice-level improvements have also been made. For example, a practice that failed to meet baseline standards in 2009/10 was offered intensive support and met qualifying criteria after six months and was thus allowed entry into the programme. It went on to score the fourth highest of all practices in 2010/1 and improved its patient feedback, after putting new systems into place and recruiting a healthcare assistant for 20 hours a week.
By Professor Ruth Chambers, GP and clinical director of practice development and performance, Dr Elizabeth Cottrell, GP academic registrar at 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.