Square roots and cut offs

It has been announced that from next year the square root formula for calculating the cash due per point in the clinical areas is to be abandoned. In brief this meant that the cash per point rose as the square root of prevalence rather than linearly with it. The theory was that there would be an economy of scale enjoyed by practices. For more information on this use the search box above to search for square root. Over time thought has moved against this theory.

In the following year the 5% cut off will go. Previously practices with less than five percent of the maximum prevalence would be treated as if they had exactly five percent of the maximum. This could create some bizarre results.

I have been asked by many people over the past couple of weeks what the effect on practices would be. Well after having a short holiday I have looked at modeling these changes based on last year's data. Before I discuss the results a couple of warnings about all that is to follow. It is a model, not a prediction. It is based on applying next year's rules to last year's data. It assumes that all of the indicators will remain the same - which is simply not true. It assumes that practice behaviour is identical which is unlikely. I have also had to make estimates at the prevalences of smoking and depression screening which were not published for England this year. These are likely to be close but not exact. I am not using the Dep 2 indicator at all. This is a model and not a detailed estimate - but it should be close.

So on with some meat. The figures for each practice are available from the left hand menu of each practices page. These are expressed in terms of the equivalence number of points gained and lost. To get the overall picture you can see the spread of practices in the graph above (I have taken eight outlier practices off the top to make the rest of the histogram clear - they tend to be unusual practices and so have unusual patterns of prevalence).

We can also look at practices in groups. Perhaps the most obvious group to look at are University practices. Dealing with younger people they tend to have a lesser incidence of chronic disease - particular cardiovascular and pulmonary diseases which dominate QOF. A rather crude search shows 26 practices in the database with the string "Univ" in their address. On average these practices lose 234 points equivalent from their QOF payments. These were the practices that started from a very low base so to lose this amount is very significant. In fact after these changes their take home points from the entire clinical domain is an average of 93. Their clinical domain is less valuable to them than the patient experience domain. This is likely to have a very significant effect on these practices.

We can also look at the effect at PCT or Health Board level. You can see the PCT level changes online or download a (7k) csv file. The winners and losers are quite dramatic. London is hit hard with both Lambeth and Westminster losing the equivalent of over 100 "full price" points per practice. The clear winners are in the North of England or attractive seaside resorts or, in a couple of cases, both. Two PCTs gain over 100 points per practice. County Durham PCT is going to have to find another one and a half million pounds per year to cover the cost of these changes. Meanwhile in Lambeth eight hundred thousand will be taken from primary care. Of course both of these could be told, more optimistically, the other way around! The message here is that although this change may be cash neutral at the national level the same is not true at the PCT level.

As the graph above shows we have a normal distribution. These changes will be moderate for most, large for some and extreme for a few - a couple of practice gain over a thousand points although they are not large but small and specialist practices.

Changes to QOF - details available

The BMA has moved faster than I have ever seen in getting details of the new QOF indicators out. After a rather vague press release this morning this afternoon produced a letter from Lawrence Buckman with a link to the details of the QOF changes.

It is only three pages and well worth a read. Highlights include the addition of a requirement for albumin:creatinine ratio in all patients on the chronic kidney disease register. This may raise a few eyebrows in biochemistry labs around the country who may not know what is going to hit them. (If they want to know what is going to hit them then a quick browse around the CKD register on the site may be useful. Around 1.8 million urine samples are headed their way.)

The current contraception indicators have gone and are replace by 8 points - six of which are for plugging coils and implants. It will be interesting to see the evidence base for this one. This will be at least a small crumb of comfort to university practices likely to be hit hard by the loss of the square root formula.

There is a bit about primary prevention in those newly diagnosed with hypertension - which should be a manageable number. In essence this boils down to finding out if they smoke, eat badly, drink alcohol and take no exercise and telling them not to do these things. I am really trying not to be cynical but very few patients are under any illusions about any of these things and it always seems a little lame.

There is a tidy up in diabetes with three thresholds including a tough 7% HbA1c (again evidence will be interesting to see). Inhaler technique is out and the MRC assessment - which is purely function is in. Actually quite a usable scale and much easier than finding an inhaler and watching them use it.

Finally depression. There is a new indicator for the reassessment of depression severity after 5-12 weeks using PHQ-9 or whatever. The patients aren't free of the questionnaires yet!

The last word has to go to Laurence Buckman - chair of the General Practitioners Committee and now Youtube star.

QOF changes 2009 onwards

Results of negotiations on next year's contract have been released last night. There is quite a bit of information although the final details are not absolutely clear.

First off there is a bit about money. There is agreement on how uplift for 2009/10 will be allocated. This may prove to be a bit academic in the current climate as it is not entirely clear whether there will be any extra cash on the table. This will be up to the DDRB. The cash will be divided up with 37% going to the Global Sum - 11% to the correction factor (to maintain MPIG) - 26% to QOF and 26% to Enhanced Services.

The effect of the above is likely to allow the Global Sum and MPIG to rise roughly together but a larger percentage increase in QOF and even large in Enhanced Services. Thus QOF is going to be a more significant income source to practices than it was before.

So what of the QOF itself? Well the big thing to go is the survey. The Department of Health has decided to do its own, by post. This is probably a relief to practices, to whom the administration was a hassle, and to those patients who feel bombarded by surveys. It may be a bit of a kick in the teeth for the nice people at GPAQ but there is of course nothing to stop people from continuing to pass them out anyway.

This will free 55 points from PE 2 and PE 6. There are also another 17 points being shaved off other (undisclosed) indicators. There is probably an interesting bit of work to show the effects of shaving points on overall achievement in those areas. These 72 points are going into new clinical indicators for which we have some vague suggestions. Official(ish) bits in bold.

• Helping to prevent the development of cardiovascular disease in people diagnosed with high blood pressure (13 pts) - other than controlling their blood pressure I assume. Possibly cholesterol measurement but this does not seem enough points for this - just measuring BP currently gets 20 points.
• Advice on long term contraception(10 pts) - for whom? Is this to combat teenage pregnancy. Long term contraception tends to be used in the over 30s - aiming to change this?
• A new indicator for depression to reduce early cessation of treatment (20 pts) - no idea how this might work.
• Beta blockers for heart failure (9 pts) - which is one of this year's new DESs
• Improvements to the indicators for chronic kidney disease (11 pts), diabetes (7pts) and chronic lung disease (2pts) - or at the very least changes.

In addition the square root formula has gone from next year, and with the uplift for those practices with less than 5% of the maximum prevalence will go in 2010/11. These changes turn things into a much simpler item of service payment once over the 40% threshold.

Developments awaited.

Updated 12:45 with points data and square root stuff.

Prevalences for 2008 (minus Wales)

	2005	2006	2007	2008
Atrial Fibrillation			1.30%	1.30%
Asthma	5.82%	5.83%	5.79%	5.72%
Hypertension	11.37%	12.03%	12.56%	12.77%
Cancer	0.51%	0.72%	0.91%	1.08%
Coronary Heart Disease	3.71%	3.71%	3.67%	3.60%
Chronic Kidney Disease			2.34%	2.92%
COPD	1.42%	1.44%	1.49%	1.51%
Dementia			0.41%	0.43%
CHD and/or Diabetes			6.40%	6.44%
Diabetes	3.35%	3.55%	3.65%	3.83%
Epilepsy	0.61%	0.63%	0.62%	0.61%
Heart Failure	0.45%	0.46%	0.80%	0.76%
Learning Disabilities			0.28%	0.28%
Mental health (05-06)	0.55%	0.72%
Mental health (07-08)			0.72%	0.74%
Obesity			7.51%	7.66%
Smoking with chronic disease			18.21%	17.30%
Stroke	1.52%	1.61%	1.66%	1.66%
Hypothyroidism	2.27%	2.46%	2.63%	2.76%

Most of this should be fairly self explanatory. The Welsh data for 2008 is not included as there is no data yet available. Mental health features in two separate rows as the definitions changed after the first two years.

There are a couple of made up prevalences in there. First is the screening population for depression which is made up of all those patients with either diabetes or heart disease or both. The smoking indicator is also based on many of the other areas. Included here is the proportion of patients with chronic diseases who smoke.

2007/8 QOF data (mostly) available now!

Another year has passed and there is a new set of QOF data to pore over. Northern Ireland published first this year about a fortnight ago whilst Scotland and England both published last Tuesday. All of the data for these countries is now online at the QOF Database. You can search for or browse the data.

I will publish the Welsh data when it becomes available. Database download will also be available soon as will overall prevalences.

Palliative care data is not visible yet either. This is due to differences in the way that this has been reported. England gives a prevalence, the other countries just give a yes or no to the presence of a register. This will take a couple of tweaks to display sensibly and I will do this soon. In any case the prevalence is difficult to make a lot of sense of. These tend to be small numbers which inevitably vary quite considerably over time.

In other site news I have removed the links to the QOF changes pages as these have become out of date as well as the extended hours calculator. In the latter case the national directed enhanced service is much less relevant as many local enhanced services filled the gap caused by its tardy arrival.

For the future I am working on ways of keeping practice data up to date, particularly addresses. I also hope to bring in links to practice websites. As I am a one man band and there are about ten thousand practices automation is going to be essential and this is taking a little time to code. It is likely to come in gradually.

QOF Research

I am always interested to see new and innovative research on the data from QOF and some of the best stuff at the moment is coming from the National Primary Care Research and Development Centre and in particular the team of Dr Tim Doran.

Two papers from this team have been published within a month of each other in two big hitting journals. The first was published in the New England Journal and dealt with the effects of exception reporting (sorry, you or your institution need a subscription to read the whole thing). In one of the more thorough analyses of exception reporting so far there is no association found between exception rates and the points offered in each indicator. Indeed the main association is with the type of indicator with low rates for offering treatment and higher rates for achieving outcomes. No evidence of systematic gaming was found in the QOF data.

In the second paper, this time in the Lancet there is a look at socioeconomic factors on QOF performance (again cash required to read the whole paper). In the early years of QOF practices located in more deprived wards tended to have more problems with attaining higher levels of achievement than those in more affluent areas. There were, however, areas of high achievement in every type of area but low achievement was concentrated in more deprived areas. Things tended to become a lot more even by year three.

There are a couple of interesting points about this second paper. Firstly there appears to be some meaningful outcome despite the fairly poor results that you get with practice based social profiling rather than patient based profiling (no cash required to read - hooray!). i.e. where patients live is more important than where the practice is located.

The second interesting factor is that points are not used for the analysis. Overall mean achievement by each practice is used. This tends to give undue prominence to lithium prescribing and patient referrals and it seems likely that most of the variation between practices is concentrated in a small number of highly variable indicators. It is still, however, much the best method of analysis so far seen in any QOF study. Clearly a team to watch!

Fat maps? Fat chance.

It comes to quite something when the best source that I can find for information about QOF analysis comes from GMTV. The big story is the "Fat Map" of the UK apparently produced by Dr Foster and sponsored by Roche. I say apparently but the actual map and report don't seem to feature on the web sites of either.

The data they appear to be using is the QOF obesity register size at PCT level for April 2007 which has been available on this site for ten months now. When you come down to the business rules level this is a measure of the number of patients over sixteen years old who have had a BMI measured (or technically weight measured and BMI calculated) between January 2006 and April 2007 and that BMI was greater than or equal to 30.

A BMI of 30 is not that high these days. For those of you who don't deal with BMIs on a daily basis (basically front line clinicians) Flickr hosts a rather wonderful range of illustrated BMI catagories.

The prevalence has then been calculated by dividing this number by the total registered patient population.

There are thus quite a number of confounding factors.

Firstly and probably most significantly is the enthusiasm of the GP practice for weighing lots of people. If people were not weighed they did not count. For instance a huge patient would not be counted as obese if they did not have a BMI recorded. Getting a high prevalence involved weighing everyone who came through the door who looked like they may have a BMI over 30. There was no incentive to weigh patients with a BMI of less than 30 so it was just not done much - GPs have a pretty good eye for rough BMIs. For this reason even if we could know how many BMIs were measured it would be a bad measure of the obesity prevalence due to the skewed population at the measurement level.

Secondly we have the dodgy denominator. Remember the definition above? It applied only to patients of 16 or over - which is fair enough. BMIs don't really work with children. However to get the prevalence it was divided by the whole population. So if you have a lot of under 16s then your obesity prevalence will tend to be diluted. Similarly if you have a generally aging population then your obesity levels would appear artificially high.

Finally we have areas such as coding which are probably pretty minor.

Wales in general seems to stick out on the map, or at least the bits I could see on news.sky.co.uk Now I don't know a lot about Wales other than what I see on Torchwood but it seems rather odd that the whole of Wales is high (from North to South) and that obesity starts right on the border. Was there a LES or other country specific reason for practices to be incentivised to check BMIs a lot?

So this is a pretty dubious set of statistics on a map. Could it be better? Well perhaps a little. I mentioned the problem of the dodgy denominator above. Is there a better figure that we could use? Certainly there is. Records 22 (recording of smoking status) applies to all patients over 15 and uses that population as its denominator. We could at least correct that error although practice rates of measurement will still be a significant factor. I will try to put the figures together and if Roche or anyone else want to sponsor it they are very welcome!

New Business Rules (v12) for 2008/9

We are now about a third of the way through the QOF year and I have just come back from my holidays to find that the new version of the QOF business rules has arrived. It is a no more gripping read than it was before and fortunately the changes are fairly minor this year. Most of the obvious changes seem to be in the area of smoking - both the clinical area and Records 22. This is the area that has received most attention this year - at least in terms of the coding areas. Just a reminder of what the guidance says:

The guidance has also been updated and in particular we would draw your attention to amendment to non-smokers and ex-smokers. Non-smokers should be recorded as such up until the age of 25 while the smoking status of ex-smokers should be for 3 years and only thereafter if their smoking status changes.

Now this has been implemented almost exactly as you see it here (for the one problem see below). Arguably there is a degree of ambiguity, and a missing bracket, in the way that the rule about three years is written but I am sure that the system suppliers can be relied on to implement it sanely. There is, however, an interesting anomaly in the way that the text above specifies the criteria. If a young man were never to have smoked by the age of 24 this would still have to be coded on an annual basis. If, however he had smoked when he was 15 and then became an ex smoker this would only have to be recorded from the ages of 18 - 20 and can then be stopped. Ex-teenage smokers are thus less work than those who have never smoked.

There are not that many young people in the smoking clinical indicators - they just don't feature in the chronic diseases that much with the possible exception of asthma and for asthmatics the smoking indicator only starts at age 20 (there is another indicator for younger asthmatics at Asthma 3). However around 80% of the practice population is also covered in Records 22, including all of the 18-25 year olds. For a typical practice this represents about 4742 patients. There are only 11 points here, around £1370 equivalent to just 58 pence for each patient in the "scoring zone" from 40-90%. It is likely that annually chasing young people who don't often attend the surgery to check that they have not started smoking will simply be uneconomic. That is not to say that nobody will do it though. For 2006/7 practices achieved 82% overall.

The recording of ex smokers for three years is however rather fragile. This may cause problems in the future although the effect should be limited this year. The problem is that the rules look only at the most recent codes and this could trip practices up. If a patient had given up smoking you could record this in years one, two and three. They would then not need a record again - ever. However if you recorded in years one, two and three - missed year four and then recorded again in year five another code would be needed in year six. The rules would see the code in year five and missed the previous year and not the three codes in the years before.

Now this is not really the fault of the rules writers. The structure of the rules is not that flexible and they have done their best within these limits. The rules have a very linear structure and there is no option for looping or iteration. The designers of QOF at the DH and the BMA are getting more ambitious with much more complex targets; the smoking rules are probably the most complex in the whole of the framework so far. Many people have big plans for new QOF areas in the future and it may be time to look at an overhaul of the way the rules are set and the systems that implement them. We are likely to see an increasing number of problems of this nature unless ambitions are reigned in a bit - and personally I don't see that happening.

Who has two?

This morning Ben Bradshaw announced in an interview with the BBC News website that he had found a practice with only two patients. It is, apparently, in Southern England.

Well I don't know who it is either. This database only lists practices with QOF returns and it contains only nine practices in England with fewer than 300 patients at at April 2007. Of these all are specialist. Most are run by PCTs as access clinics - often these are catering to the homeless or others who may find it difficult to register with conventional practices. These practices will run under PMS contracts which don't attract the MPIG that Mr Bradshaw doesn't like. There are two other specialist practices, one attached to a very large nursing home and another to a school, but both of these latter two have over 150 patients.

So the mystery of the practice with two patients remains.

David Cameron adds some flesh

Nearly a year and a half ago I wrote here about the Conservative "Outcomes Not Targets". Well we have a bit more flesh on the bones with the release of the green paper "Delivering some of the best health in Europe".

Now obviously I come at this from a certain angle. What does it mean for GPs and especially QOF? Well the answer is initially not very much. QOF only gets a single mention in the whole of the Green Paper and even then it is only in passing. Most of the examples related to hospital care. We do get a feeling for the way that thinking is going though.

The paper acknowledges that outcomes are difficult to measure in any objective way and at individual patient level it is almost impossible. There are public health and systematic outcome targets stated in the paper but at the individual patient level the big thing is Patient Reported Outcome Measures or PROMs. It would be over simplistic o liken these to the little cards you get in hotel bedrooms with a chance of winning a free holiday but that would not be a bad place to start thinking about them. How these are to be translated into cash incentives is not clear but this is widely used in industry. When I bought a new car recently the salesman explained that much of their commission was based on these things and they would be very grateful if I could hold back my British reserve and go for excellent rather than very good. They had helpfully laminated an example with the excellent column highlighted. Similar things seem to be happening in education.

The other big thing is that the information will be freely available in a pretty raw form for others to turn into services to patients.

Our policy generates significant value for the NHS that far outweighs any potential cost implications. The NHS will not be expected to do anything other than collect, collate and publish the required information. Experience in other areas and other countries – such as crime mapping in the US – shows that third parties like Dr Foster, Google and others can creatively use this data and turn it into products that are available to patients and commissioners at zero cost to the user.

Well that is why I try to do here! The phrasing certainly plays down the difficulty, complexity and quantity of the work that the NHS will have to do but it is also true that there are several such mechanisms already in place. A lot of data is already generated and opening this up would be very welcome. This struck a chord when reading about suggested architectures for public information. In that architecture the analysis layer can be repeated many times but this seems a pretty good way to open public data to imaginative analysis. This is much more the US model where the government is forbidden from owning copyright on anything coupled with a rather more permissive freedom of information legislation.

But with all of these thing I like to see specifics. There are lots of specific examples in the Green Paper of problems with the target regime. I would love to see just one worked example of a PROM and its consequences for the provider. Another year perhaps?

Supporting Surgeries

If there is one thing that QOF has taught us it is that most GPs respond to a challenge. In the first year the government was surpised at the levels of achievement seen, although this was largely a repeat of the situation with Item of Service payments in the 1992 contract. GPs it seem, will do what is required to meet the contract.

We may have met our match, however. When the requirement is largely that you are not a GP but a large corporation it is an impossible target to meet. With hundreds of individual and different contracts it also become impossible to collect consistent statistics and monitor the performance of the corporate clinics - just when we seemed to be getting started on that problem.

We have seen this already with independent treatment centres. For years there was a persistent rumour of poor outcomes from these centres but no good figures to back these rumours up. There is some data now which suggests that there is little difference in outcome from NHS centres but nobody benefited from a five year delay in collecting the statistics.

We risk a distraction of GPs from the patient sitting in front of them and their needs by the central declaration of needs and solutions from central government. Anything else is a risk to the patients in primary care. This is why I support the Support Your Surgery campain.

Pretty Charts

Since the new indicators appeared on the site last September the chart of prevalence on the practices page has been pretty awful. It was almost impossible to read the key at the bottom. This was a major limitation of the charting app I was using.

Well now there is something new. Thanks to the rather wonderful Fusion Charts there are now simple and clear charts. The downside is that they do need flash. However the way they work means it will be much easier to add new charts to the site in the future without a huge amount of extra work for the server to do.

Enjoy.

QOF changes

A couple of weeks ago the BMA issued its guidance on the QOF changes for this year. Basically some organisational areas were cut and the points transferred to two new areas to be based on surveys of patients.

The survey questions seem likely to be very similar, if not identical, to those asked about appointment booking in the 2007 patient survey.

As we have some data to go on, for England at least, the effect of the changes can be modelled at practice level. In fact I have done this for all practices in the UK, simply the results are likely to be less reliable outside England. In particular the square rooting of the COPD prevalence is based on the English average - slightly overestimating losses outside England.

To find the data for individual practices just use the search or browse pages to find the practice and then select from the menu on the left side.

Exception reporting (again)

The beast of exception reporting is rearing its head once again, this time in an article in the Health Service Journal (registration required) and in an editorial. What is being looked at here is raw practice data, similar to that produced routinely in Scotland without very much statistical analysis.

Helpfully there are some selected practice level details published by HSJ (5.6Mb Excel) and a summary at PCT level (PDF). In the articles this has been looked at in a journalistic way by finding the extremes and putting them in the headlines (and of course the blogging style is gross generalisation!). Simple things like the standard deviations are essential to give some idea of whether these extremes are the result of chance or other factors. For instance if we measured the height of all GPs we would be surprised if the tallest were ten times as tall as the average. However if we measured the number of suits owned it would be less surprising.

For a start I have looked at a box/whisker plot. In these the box contains the middle 50% of practices and the whiskers contain most of the rest with outliers plotted individually. We see from this that most practices are within quite small ranges.

I have written quite a lot about exception reporting. Analysis is difficult due to multitude of potential reasons for exceptions. We do not see any breakdown on the reason for exceptions in these statistics. QMAS collects the reasons to some extent, and this is visible at practice and PCT level. Although practices with high list growth are removed practices with high list turnover remain in the table. As new patients are automatically excepted this could have a significant effect on the data.

It is difficult to draw any conclusions. That would make the editorial a little dull though.

Many GPs will have made countless calls, sent innumerable letters, to try to goad their wayward patients to face up to their health risks. But the suspicion must remain that many patients have to all intents been dumped out of the NHS; the GP has given up on them, and too many PCTs are failing to bring these patients back.

I would suggest quite the opposite. These patients have given up on the GP and treatment. It is the place of the health service to inform and not to coerce. You can only try so hard. What is suggested is what has been described as a tyranny of health. The words goad and wayward suggest an extremely paternalistic view of the healthcare system. We can look back on the removal of patients from practice list for failure to comply with previous targets and are thankful that exception reporting has taken us away from there. We must not go back.

Updated 8th April

I have updated the boxplots with better ones (see the comment below). I should probably just leave the defaults on my stats package! There are quite a lot of points plotted but it is important to remember that there are around 8000 practices being plotted here. Even 1% of practices represents eighty of them.

QOF changes for 2008/9

The BMA has released details of the changes to QOF targets for the year 2008-9. Actually this is more a summary of where the changes are as the detailed guidance is not yet out, and it is in the detail that the interesting details are located.

The headline is probably the removal of fifty eight and a half points largely from the organisational domain but five points have also been take from the COPD spirometry measurement section. The spirometry has also been made more explicit in asking for post bronchodilator spirometry.

There are some other minor changes. They are worth knowing early because they may be difficult to catch up with later in the year. There is now a requirement to refer all patients with stroke or TIA within one month of diagnosis. Along with the spirometry changes this will apply to new diagnoses from the first of April 2008. The reference date for ECG investigation in atrial fibrillation has also been moved to the same date.

One of the changes with widest effect may be the changes to the smoking area - particularly as it affects around one in five patients. As it stands this refers only to the clinical area on smoking which refers to those with diabetes, cardiovascular and lung disease. Patients with psychotic and bipolar disease have now been added to this area (probably a drop in the ocean) and the criteria have changed. Currently if a person had never smoked then you didn't have to ask them again. If they had ever smoked they needed to be asked annually. Now all patients under 27 need to be asked annually and you can stop asking those 27 and over who have never smoked or have not smoked for over three years. My sympathies go to whoever has to write the business rules for that one.

In practical terms this is likely to mean fewer patients needing coding over the course of the year as there are few patients under 27 years old on the chronic disease registers. The BMA guidance seems to suggest that there is to be no change to the organisational smoking indicators which apply to the whole of the practice population over 15 years old. As it stands it would appear that the old rules (if they have ever smoked then you need to ask annually) still apply to RECORDS 22. This would seem to be an odd situation, but I am sure that they have spotted it already!

Finally prevalence day is being moved to March 31st from next year which makes a lot more sense. It takes seconds to do the calculation on a computer and allowing six weeks turned out to be overkill.

Update 1st April

A Department of Health letter landed on my desk today confirming that the smoking rules apply to both the clinical and organisational sections.

Surgery search improved

I have changed the search system slightly to (hopefully) give better results. Previously you could use wildcards e.g. Car* would give Carlisle and Cardiff. This was hardly ever used and the search tended to give very long lists of unhelpful results.

You now can't use wildcards but the results should be better. For more general QOF queries over many web sites the Google search is still there. It searches on selected QOF related sites without all of the stuff about GnuCash and Hebrew characters you tend to get on a full Google search.

The vote is out

The GPC announced the result last week of the poll of GP opinions on the two possible contract options from April. The summary is basically that GPs are not happy but have voted for option A as the least worst of a bad bunch. Lots about this in the media although some have portrayed it as an agreement to do extended hours. It is not. This was about what will be taken away from practices. Whether practices offer extended ours will depend on the DES specification. That judgement will be made individually by the 8000 odd practices in England and in similar ways across the rest of the UK and Ireland.

In practical terms for this website it means that the loss calculation is no longer relevant as it only applied to the potential imposition. There is simply not enough data available to calculate the loss for the current proposals. The DES calculator is still running with the best information that is coming out in an official form. You can find a link to this in the left hand menu on the practice summary page for each practice. This applies to England only as there was no comparable patient survey in the other countries, or at least not one that I am aware of.

I am taking the link to the loss calculator off the practice pages to avoid confusion. The direct URL should work for the foreseeable future but if you want or need access to the data then drop me a line.

Six million people can be wrong

There are a lot of statistics bouncing around about extended hours. One that keeps coming up is the demand of six million patients for them. Here we have no less a figure than the Secretary of State for Health answering a question in parliament.

About 6 million people in our patients survey said that they want improved access to their GP in the evenings and on Saturdays, which is why we are seeking to reach a negotiated settlement with the BMA.

The survey he seems to be talking about here is the 2007 GP patient survey. Looking at the results things are not quite as clear as they might seem from the above answer. For a start six million people did not say anything of the sort. There were not even six million in the survey. The survey was only sent to 4.7 million people and less than half of them (2.3 million) sent it back. The people sent surveys were picked largely from those that had been to their GP in the previous six months.

So where does this figure of six million come from? Well out of those who replied 16% said that they were, in some way, dissatisfied with opening hours. Take that figure together with the population of England over 18 (just shy of 40 million) - multiply and you get a figure of around around about six million. Clearly what Mr Johnson intended to say was that if the whole adult population had been asked and they all replied he believed that six million people would say that.

Now that is a pretty rotten bit of statistical conjecture. It assumes that all of those people who did not reply would think the same way as those who did. Of course it may be they did not reply because they had not particular views. Even more ambitiously it assumes that that group that were not polled - people who had not seen their GP recently - had identical views.

Worse still it ignores the fact that only ten per cent were able to say in what way they were unhappy with the opening hours (lunchtimes, evenings etc). Only 208,000 asked for increases outside of the usual 8-6.30 Monday to Friday - about 9% of the total responses. It is difficult to call this a massive pressure. Even with the simplistic extrapolation this would only be 3.6 million. The pie chart graphically shows the responses (click on it to enlarge).

Its not just me saying this. When you pay 11 million pounds for a survey MORI gives you some quite detailed analysis - in this case 111 pages (2.4Mb) of it. So what do the experts have to say?

When interpreting the findings, it is important to remember that the results are based on a sample of patients registered with a GP in England who responded to the survey, and not the entire population of England.

The vast majority of patients (84%) say they are satisfied with the hours their GP practice was open during the last six months, while the remaining 16% say they are dissatisfied with the opening hours.

What do we know for sure then? Simply there is some demand for extended hours, but not a lot. You can read the MORI report for some detailed socioeconomic breakdown of the figures. What is quite clear though is the figure of six million people is definitely wrong.

Changes to Extended Hours DES

In the fast(ish) moving world of GP contract negotiations the finances of the extended hours DES have changed again. In his latest letter to the profession Lawrence Buckman has announce an increase in the rate of payment from £2.80 to £2.95 per patient for extended hours. It has also been clarified that the survey will be in QOF and not part of the extended hours DES

This is in general good news - there is more cash for providing extended hours under the DES although and this is surprisingly substantial for many practices. I have updated the extended hours calculator which can be accessed from left hand menu the practice pages.

I have also corrected a bug which overestimated the hours required for about one in six practices. Sorry about that and thanks to the eagle eyed reader who spotted it.

The contents of the DES are still far from fixed as you can see here and here.

Questions in the House

Perhaps an old fashioned phrase to describe a significant event but there have been questions in Parliament about the QOF. At health questions this week the Alan Johnson defended of putting cash into extended hours rather than clinical areas. He accused the BMA of propaganda in suggesting the reverse. That suggestion seems to have produced a sharp intake of breath from the Honorouable Members. Ultimately though, like most parliamentary answers, there is more heat than light here.

Overextended?

The changes to the QOF detailed on this blog and the detailed calculations of losses under the proposed contract imposition are only a relatively small part of the current issues between GPs and the government. The central issue from Numbers 10's point of view appears to be extended hours. If the governments proposals are accepted then a Directed Enhanced Service will be commissioned for these extended hours. The politics are complex an I would direct the interested reader to Lawrence Buckman's letter to the profession.

The fundamental drive of the DES is that there should be 30 minutes of extra time per one thousand patients on the list to be delivered in 90 blocks in the evening or weekends or 60 minutes in the mornings. We are, however on shifting sands here. A new provision brought in at the end of January is that there should be no time when reception is closed during the core hours. Any reception close would have to be replaced with clinical time. The extended hours would be agreed with the PCT and based on the results of the GP Patient Survey, a national survey of patients about primary care.

The results of the patient survey have been published and so the figures can be used to work out an estimate of the impact of the DES. What I have done on this site is to calculate the amount of time required from each practice and then allocate those hours according to the result of the survey. Thus is 51% wanted weekend access and 49% evenings and there were two sessions to allocate then there would be one to each. If there was only one it would go to the weekend. A fairly simple formula but it does make it easy to automate. The ultimate detail is in the source code.

The results can be seen on the practice pages. The summary is that it is not the couple of hours a week that many imagined. 55% of practices will be required to produce three hours or over on a Saturday. Around 160 practices would also be doing Sundays under this formula. Interestingly only eight practices would be required to provide early morning surgeries.

Some of the problems with the current proposals are also seen. It is widely reported that simultaneous surgeries would not be permitted (i.e. you could not supply three hours of time by two GPs working for 90 minutes simultaneously). One of the effects of this rule is that opening hours for smaller practices will be considerably less than those for larger practices. Under this rule two practices would be open from 8am on Saturday until half past midnight on Sunday morning. Clearly this is absurd.

I will try to keep the model updated with changes, but there remains a lack of detail in these proposals, and much of the detail that does exist may not be that practical. Obviously if anyone from the government side of negotiations knows better then the email address is below!

Who loses what?

As many of you are probably aware the site has had information about the potential loss of cash to practices under the government's proposed imposed changes to the QOF in England. If you have not seen this you can click on the link on the left of each of the practice pages. There is also table of the changes effects at PCT level.

Of course now that we have these statistics we can look at the breakdown a little. As I have said before the threshold changes will mostly affect those who have had most problems in meeting the targets. The practices that have tended to have lower score have tended to be those in more deprived areas. A reasonable hypothesis would be that more deprived practices tend to loose out more.

We can go onto test this. Helpfully the deprivation index for most practices was published as part of last year's GP patient survey. We can put all of this together in a spreadsheet and work out the loss per patient for the threshold changes and overall for whole set of changes. Not difficult as we have practice list size from the QOF data as well.

As it turns out there is a correlation between the deprivation and the cash lost through threshold changes at practice level. For the mathematically minded the correlation is 0.13 - not particularly strong but it is there. In practical terms the thousand least deprived practices are to loose 62 pence per patient whilst the thousand most deprived practice will loose 84 pence per patient - a difference of 12 pence. For a "typical" practice of 5891 patient this works out at £1,287 per year between the most and least deprived practices.

This all looks pretty bleak but there is another factor that works against this effect. The removed points take more from practices that have gained all of these points in the past. Statistically these tended to be practices in the least deprived areas. If we bring in the removed points then the effect almost disappears. The correlation drops to 0.03 which is small enough to be ignored.

So balance is restored - whether by luck or judgement! It does however give some idea of the less obvious effects of changes to QOF.

Less cash for QOF says HMG

It has been a busy few weeks. Just as I was starting to digest a report suggesting the development of the QOF then the negotiations for changes to next year's GMS came crashing to a halt. The report is still worth reading, if only for the summary of research done with QOF data thus far.

There is a pretty good summary of the situation in a letter from Laurence Buckman - chair of the GPC which I would recommend reading. In summary, for the impatient, the government (only in England for now) is imposing changes to the contract to move cash from QOF and Choose & Book and put it towards increased hours of availability. This, we are told, its only priority for primary care this year. Arguably this is a move from quality to quantity

As far as QOF is concerned several indicators are to be removed taking with them a total of sixty points.

• Holistic points (20 of them) - points for consistency - all gone
• Records 3 (1 point) - communication with out of hours service
• Education 4 (3 points) - induction training for new staff
• Management 2 (1 point) - computer back up
• Management 4 (1 point) - instrument sterilisation to national standards
• Management 6 (2 points) - job description for all new posts
• Management 10 (2 points) - employee procedure manual (absence, bulling etc)
• Medicines 4 (3 points) - repeat prescriptions in 72 hours - 48 hour target remains
• Medicines 11 (7 points) - medication review for patients on four or more medications (review for all patients remains)
• CS 5 (2 points) - there is a system for inform women of smear results
• CHD 12 (7 points), Stroke 10 (2 points), DM 18 (3 points) and COPD 8 (six points) - flu jabs in high risk groups

As there are 1000 points in the QOF a rather obvious bit of maths shows a 6% drop already. There is more, however. Initially the scoring area for each of the indicators started at 25%. This was increased two years ago to 40% and this new imposition will increase it to 50%. The top thresholds for payment will also be increased to something around the mean of current achievement. This second part is likely to be more significant for most practices. Pretty much by definition half of practice would be expected not to hit this higher threshold.

The effect of all this remains to be seen. We already know that exception reporting tends to be reactive - i.e. there is more exception reporting when below the threshold than above it. This is largely because practices stop reporting when they get over the threshold. It would not be unreasonable to expect a bit of an explosion in exception reporting with these changes. Of course there will almost certainly some increase in achievement but the extent is uncertain.

We can use the data we already have to try to model the effect of these changes - and apply them to last 2006/7 data although with the caveat above. This should be online in the next day or so.