Acting Director of Planning and Primary Care, Carmarthenshire Local Health Board, Llanelli, UK
Received date: 5 April 2005; Accepted date: 12 April 2005
The Quality and Outcome Framework (QOF) is a financial incentive system for the provision of quality primary care medical services within general practice. It is measured using a points system of 1050 maximum. This paper provides an overview ofthe QOF process undertaken in 26 general medical practices in Carmarthenshire, south-west Wales. Using a consistent approach across clinical and non-clinical domains, the Carmarthenshire Local Health Board (LHB) QOF visiting team were able toidentify examples of good practice. Furthermore, the QOF points achieved by the practices suggest a quality primary care provision within Carmarthenshire. The QOF has been a learning process for all stakeholders involved in the process, and a formalevaluation of it within Carmarthenshire would now appear to be a sensible step forward.
Carmarthenshire, evaluation, good practice, primary care, quality
Carmarthenshire Local Health Board (LHB) serves a population of approximately 175 000 individuals in south-west Wales. Between December 2004 and February 2005, all of the 26 general practices within Carmarthenshire were visited as part of the Quality and Outcome Framework (QOF) process which forms part of the new General Medical Services (GMS) contract within the United Kingdom (Box 1).
The LHB had a core visiting team derived from the medical, nursing and service planning and develop-ment directorates (see Acknowledgements). In addition, community health council representatives attended four visits.
A visiting timetable was constructed in consultation with the practices, and prior to each visit a pre-QOF meeting was held to review the evidence provided and identify any issues to be raised during the visit.
Although the size and constitution of the visiting team varied, during the visit a consistent approach was taken. The non-clinical domains were discussed with the practice manager while the clinical domains were discussed with at least one of the general practitioners (GPs). For both the non-clinical and clinical domains, a standard template covering all of the domains was used. The non-clinical domains covered: records and information about patients; patient communication; education and training; practice management; medi-cines management; patient experience; and additional services. The clinical domains covered coronary heart disease; stroke; hypertension; diabetes mellitus; chronic obstructive pulmonary disease; epilepsy; hypothyroid-ism; cancer; mental health; and asthma.
The QOF report was written up in a standard format and sent to the respective practice for com-ment. Within the report, areas for action were ident-ified and an overall impression of the visit described.
It was apparent from the visits that variation across general practice exists within Carmarthenshire. For example, some were unable to fully use the Contract Manager software, while others used it for maximum effect. There was also variation in some of the proto-cols, for example smoking cessation and support offered to carers.
One of the most important variations related to repeat prescriptions and medication reviews. The QOF requires evidence that an indication for the repeat prescription can be identified in the records, and that patients have medication reviews. In order to build on good practice identified during the visits and to achieve equity, a standardised template was developed for completion in order to achieve the points.
The average level of points achieved by Carmarthen-shire practices in 2004–05 was 954, a figure slightly higher than the all-Wales average of 943. Table 1 provides a summary of the QOF points achieved within Carmarthenshire. From the data, it can be seen that more than 95% of practices exceeded the ministerial priority target for primary care (25/26), and that the majority (22/26) achieved points exceeding 900. One practice achieved the maximum 1050 points.
The QOF points achievement that exceeds both the all-Wales average and the ministerial priority target would suggest a quality primary care provision within Carmarthenshire. Further work is required to evaluate the achievement in more detail, and the substantial information and experience obtained during the QOF process will provide a basis for this. Arising out of the work will be actions to ensure that all learning points are implemented within Carmarthenshire. Some of these learning points are evident now, and the Discussion that follows provides commentaries on some of the QOF experience gained during the process.
The QOF process proved to be a substantial under-taking. The immediate gains of it have been the engage-ment with the 26 practices and the initiation of a continuous quality improvement process that can be developed further. Continuous quality improvement is a key issue, and perhaps the QOF process may facilitate this in many ways, including promoting reflective practice.[2,3]
Where possible, the visiting team tried to resolve issues during the practice visit. This included issues relating to data quality, and also signposting the practice to another professional for further informa-tion. For example, with respect to carer support the ‘Carmarthenshire carers’ information pack’ was con-sidered to be an essential resource. When the pack was not available, the practice was given the contact details of Carmarthenshire Voluntary Service in order to obtain them.
The variation identified allows consideration to be given towards developing standards of good practice within the Carmarthenshire context. The advantage of this approach is that variation can be reduced, and also the good practice is an internal standard generated within the county rather than imposed from outside. Patient experience and involvement is also a key element within this development.
In conclusion, the QOF points achieved by the practices suggest a quality primary care provision within Carmarthenshire. The QOF has been a learning process for all stakeholders involved in the process, and anecdotal feedback has been generally positive from both practice managers and GPs. A sensible step forward now would be to formally evaluate the QOF process within the wider context of continuous pro-fessional development. Such an evaluation might also provide useful information about how a financial incentive quality improvement system leads to service changes within general practice that benefit patients.
The QOF visiting teams comprised the following:
Dr Terry Davies (Medical Director)
Nicola Gravette (Clinical Governance Officer) Kath Haines (Prescribing Manager)
Dr Bryn John* (Neath Port Talbot Local Health Board Medical Director)
Lynne John (Assistant Nurse Director)
Paula Jones (Primary Care Development Manager)
Gareth Morgan (Acting Director of Service Planning and Development from 31 January 2005)
Karen Preece (Director of Service Planning and Development until 31 January 2005)
Chantel Rhodes (Data Quality Facilitator)
Dr Michael Thomas* (Local Public Health Director)
Bridget Wilson (Commissioning and Planning Officer)
*Attended one visit on behalf of Dr Terry Davies
Karen Hackett (administrative support) and Ceinwen Richards (work on QOF reports) are thanked for their hard work supporting the process.