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.