Who has two?
Thursday, 3 July 2008
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.
Labels: media
David Cameron adds some flesh
Sunday, 29 June 2008
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
Monday, 19 May 2008
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
Sunday, 18 May 2008
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.
Labels: site news
QOF changes
Wednesday, 9 April 2008
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.
Labels: QOF_review, site news, survey
Exception reporting (again)
Sunday, 6 April 2008
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.
Labels: exceptions
QOF changes for 2008/9
Sunday, 30 March 2008
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.
Labels: QOF_review
