2011 Data online - and the new site

I am delighted to be able to say that the 2011 data is on the site, and the new version of the site is on line. This currently mirrors of the function of the old site with more detail at the SHA, country and UK level.

There is more functionality to come which is made easier by an entirely new data model in the background. The database will be able to cope with things such as comparisons between years.

There is also a new look which is hopefully easier to find your way around. Search is on pretty much every page. Please do let me know how you find it. Everything can change and this is rather more simple in the new site. I have used Django to build the site which has a very simple template system. I would update the look to this blog but Blogger templates are such horrible things that I really can't figure out at all.

The downloads should be available soon. I need to tidy the database a little first.

Update - and coming soon!

I have not written here for quite a while, at least partly due to there being little going on until the past couple of weeks. I have been writing for the GP Business magazine though in that time.

The data for all four countries has now been released and I am getting it onto the database currently. I am also giving the site a makeover from top to bottom which will increase what is possible and make the whole thing more maintainable. It will also have a new look, have less clutter and have graphs that work where there is no flash (ipods,pads and phones mainly)

This is a pretty big change so I will have to take the site down for 24 hours or so in the next week before it reappears with all the data. New features can be added after that.

Hope to see you there soon!

Blood pressure monitoring

Lots of stuff on the news today about the NICE guidance that all new patients should have an ambulatory blood pressure measurement. Savings of about ten million pounds in five years are promised. But what is the cost?

We can use the QOF data to work this out. As the PP1 indicator applies to all newly diagnosed hypertensives then the denominator is a good indicator of how many have been diagnosed in the previous year. (Acutally it underestimates buy up to 8% but I will let that pass for just now.) The total of the PP1 denominator over the UK in 2009/10 is 278,012

We can buy an ambulatory blood pressure machine. If we pick a decent supplier - I promise I am not on commission here - the cheapest today is £1350 including VAT.

As they go on one day and come off the next these could be used four times a week in most practices - 208 times a year.

Lets do a little bit of maths - 278012 patients per year divided by 208 slots (lets assume perfect useage) needs 1337 machines. At total cost of £1,804,404.

Of course if use is less than perfect - and to operate at all there will have to be some free slots - then the cost will be more. Possibly two to three times as much. This is a big upfront capital cost. Recurring costs will need to be added on as well as replacement costs. I would imagine a machine is going to start to look pretty shabby after 208 uses!

Incentives work

The role of the press office at a major journal is to try to get the journal into the mainstream press. They can tend to be a little, well, excitable.

So it was in last weeks BMJ that a paper was published on the early years of the QOF. Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework is actually quite an interesting paper on the effect of incentivised and non incentivised indicators. The not terribly startling conclusion was that attaching a third of practice income to a set of indicators seems to have concentrated the minds of GPs and influenced practice, or at least the coding of that practice. Incentives work.

The graph above is taken from the paper. You can clearly see the "hump" where QOF starts. The setting up of sytems and templates in a concentrated way has pushed up achievement and this is maintained (or "plateaued" as they say in the paper).

However most of the press attention went onto the green line. Notice how the green line plummets off the bottom of the graph indicating inadequate care? Nope, neither do I. It is still going up. It is not going up quite as fast as before, and that is the point that the paper makes.

It is not a scandalous or surprising conclusion. Paying a third of income and a greater share of profits for certain indicators is bound to put these as top priorities. It is to the credit of general practice that the standards for the lower prority areas have not simply been maintained but continuously improved.

To be startled by the result that incentive payments incentivise some things over others is to question what you thought QOF was actually for.

Read codes for new indicators

With impressive speed version 19 of the business rules has been released. This is likely because rules are developed alongside the indicators at the NICE committee stage. The sign off date for this set of rules is given as December last year. This certainly makes things easier for practices and, perhaps because of the extra time, the rules seem pretty well put together and well annotated.

So what is new this time? It is of little surprise that it is in mental health where the biggest changes are. Most of the other changes to indicators were fairly simple. Where there are lots of new indicators here there are also lots of codes.

There is, however, some chance of patients getting off the mental health register for the first time. Strangely this is not through the 212T resolved code but through remission codes for individual diagnoses. These are spread around read codes and all state remission rather than resolved. The implication that once you have mental illness it is never really gone remains. Use of these codes does not reduce disease prevalence for a practice.

First up is recording of alcohol consumption. In general codes starting 136 count but there are some odd exceptions to this. Code 136 on its own with a quantity would be fine. Anything which says unknown does not count. There is a list of "bad" codes and some good equivalents below.

Codes not countedCodes which are counted
136W Alcohol misuse136T Harmful alcohol use
136M Current non drinker1361 Teetotaler
1369 Suspected alcohol abuse - denied136S Hazardous alcohol use
136Y Drinks in morning to get rid of hangover
136b Feels should cut down on drinking136K Alcohol intake above recommended sensible limits

The guidance states that lipids test must be for a TC:HDL ratio - this is certainly not the routine in my area. Even worse the only code currently allowed is 44PG HDL:TC ratio. This is the inverse of what the guidance asks for. Our lab certainly reports 44PF which would be the correct code here. This is clearly silly and I would hope that this would be corrected in the next version.

The codes for other areas of mental health are fairly routine. Glucose testing is not required for patients who have a diagnosis of diabetes although the test is still counted if they are diagnosed during the year. The sample can be fasting or random.

Another complex area is advice to women who are having advice about epilepsy and fertility. This applies to women who are between ages 18 and 55 inclusive at the end of the year. They require separate codes for contraception 6110, pre-conceptual 67IJ0 and pregnancy 67AF counselling. All three codes or their exception codes must be entered every year. Useful information available from Epilepsy Action including a pdf leaflet (top right corner). Beware the "printer friendly" is a tree unfriendly 61 pages long!

Diabetes foot risk assessment is fairly straightforward using codes 2G5E-L. The rules are made a little more complex as they exclude bilateral amputees but this should not cause too much concern to practices. Just remember that they still need sensation testing (29B4-9 or 29H4-B) as well.

CHD 13 is the indicator that says new angina patients should be referred for specialist assessment. Excercise testing is not longer required, or counted. Referral codes 8H44, 8H4R, 8HTJ and 8HVJ count. Unfortunately NICE says that barn door angina does not need specialist assessment so exceptions will apply. There is no specific exception code so they would need 9h01 (excepted from CHD indicator, patient unsuitable) to be used. This is less than satisfactory. I would hope this would be sorted on the next release or they will requiring excepting from the whole of the CHD section every year.

Effectively the referral needs to be within 3 months before or after the diagnosis although within the same QOF year following diagnosis is also fine.

That is about the most I can spot at the moment. Most of the other indicators have changed in fairly minor or predictable ways. It is to be hoped that the obvious errors will be corrected soon, indeed it may be that version 19 is never actually implemented if version 20 comes out soon. The real message at the moment is to get cracking on the mental health checks and the epilepsy advice.

(Apologies if you have seen this post up and down over the last couple of days. Blogger crashed in a fairly major way and they had to get this from backup.)

Things to do now

GP Business magazine asked me to write a couple of articles which they have now put up on their website. The first gives some hints on what to do now to maximise your QOF achievment this year. It is important not just to get the points but to maximise prevalence. Adding one patient with diabetes can add over £50. Much more from the link above.

The second is a first guide to the QOF changes for this year. There are quite a lot of smaller changes and many are worth getting on with now.

Some of my points are missing

Yesterday the changes to the GMS contract for the year from the first of April came out. there are quite a few of them and the full details are on the BMA contract page. Of course I turned to the QOF changes first of all. You can read the full QOF changes here.

You can almost feel the negotiations behind them. Raising the upper threshold on three indicators from 70% to 71% seems likely the result of a very long and banal meeting. Other areas have other minor differences and some, such as mental health see big changes. There is also a lot of "to be announced" around prescribing and referral audits.

I am trying to write and article for a trade magazine about the changes but I have hit a problem. The numbers just don't add up.

Page one goes pretty much as billed with 92.5 points being removed. Page two then gets a little odd. CHD11 (ACEi after MI)become CHD14 with 3 extra points. DM9 (foot pulses) gains a point but also does most of what DM 10 currently doing. Is this duplicated or is there another three points lost here? So at the end of page two we have lost 92.5 or possibly 95.5 points and gained 4.

Page three - MH 9 gains four points in its split up but depression loses 20. So total 8 gained and 112.5 (or 115.5) down.

Page four has lots of new indicators so gains 40. Now 48 up.

Page five gains 48.5 but loses another 4. Final total 96.5 gained with at least 116.5 lost. 20 points have gone adrift somewhere. Even worse there may be another 3 if they don't want to pay twice for foot checks. And actually I wonder whether they will really want to have two indicators for aspirin and beta blockers in CHD which would lose another 14.

So where are my 20 points?

Updated 14/3/11 They have been found and it seems to have been the slip of a keyboard. QP9-11 which relate to reviewing emergency admissions should have 47.5 rather than 27.5 points. That is a lot of points, nearly 5% of QOF - more than all of asthma.

QOF error in your favour - receive £???

This statement has appeared on the Primary Care Contracting site

An error has been identified within the QMAS system which calculates payments to GP contractors under QOF and which has resulted in GP practices being underpaid for achievement under the QOF additional services indicators since 2004/05. The Department of Health will provide PCTs with resources to make good these underpayments.

... and that is all we have. There is no detail of what the error is. The additional service domain contains Child Health Surveillance, Cervical Cytology and Contraception/Sexual Health. There is a prevalence adjustment here and I would guess that that is where the problem is.

It is worth noting that this seems to have purely been an underpayment and some practices could be due six years of back pay.

QMAS is used to calculate the QOF in England and Scotland although PCC only deals with England as far as I know.

A notice on QMAS says the system will be off for a couple of days from the 11th February. I have no idea if this is connected.

Does QOF work?

There is quite a bit of publicity today for a paper in the BMJ asking whether hypertension targets have any effect on outcomes. Neither blood pressure or cardiovascular morbidity seem to have been affected.

It was with a sense of dread that found the paper. QOF has had more than its fair share of thinly disguised rants appearing as research. I was however very pleasantly surprised to find a well constructed piece of research with tightly defined methods and considerably clarity of thought. Maybe it takes researchers in the USA (Harvard to be exact) to look at these things objectively.

There is considerably debate about performance related pay and very variable evidence about how effective it is. There has been some research in the USA where schemes tend to make up a much smaller proportion of practice income than in the NHS.

It is of course disappointing although not particularly surprising to see a lack of observable effect. QOF is not, of course, a controlled intervention and it is possible to argue that we will never know what would have happened without it but this is pretty weak.

Now for the political bit. The cash for the QOF came, to a large extent, from a transfer from the old capitation payments. So the pay which previously went to practices and was used for treatment of hypertension was paid, in a different way, to practice for the same treatment of hypertension.

So little change but I am strangely cheerful that it has been demonstrated in such a high quality piece of research. More please.