Smoking 3 - % of Patients with Any Or Any Combination of the Following Conditions: CHD

QOF Achievement
2007-2008 End of Year Achievement Points
2007/2008 End of Year Overall Achievement / Domain / Maximum Points / Achievement Points

Clinical

/ 655
Organisational / 181
Additional Services / 36
Patient Experience / 108
Holistic / 20
Total / 1000
Disease Prevalence

Details of disease register prevalence, as reported on QMAS are detailed below and are compared to the expected prevalence for each disease area. Where there are significant differences between the national/PCT prevalence and the practice prevalence a suitable explanation will need to be provided to explain the variation e.g. high proportion of elderly or young patients. (as a guide a significant difference is where Prevalence Factor is outside of the range 0.8 to 1.2 caveat where cut off has been applied)

Prevalence = (Disease register size / list size) *100

Disease area / Practice Prevalence
(%) / PCT Prevalence (%) / National Prevalence
(%) / Prevalence Factor / Explanation for Difference, if applicable
CHD / 3.51
HF / 0.75
Stroke and TIA / 1.63
Hypertension / 12.76
Diabetes / 3.85
COPD / 1.47
Epilepsy / 0.60
Hypothyroidism / 2.69
Cancer / 1.07
Palliative care / 0.11
Mental Health / 0.73
Asthma / 5.77
Dementia / 0.41
Chronic Kidney Disease / 2.90
Atrial fibrillation / 1.29
Obesity / 7.52
Learning disabilities / 0.26
Smoking indicators
SMOKING 1 / 21.16

Visit Date………………………

CHD 6 – The % of patients with CHD in whom the last blood pressure reading (measured In the previous 15 months) is 150/90 or less

Number / Computer. ID / Record of Blood Pressure in last 15 months / BP
Value recorded / Last recorded Blood Pressure (measured In the last 15 months) is 150/90 or less
1 / YES/NO
Date: / YES/NO
2 / YES/NO
Date: / YES/NO
3 / YES/NO
Date: / YES/NO
4 / YES/NO
Date: / YES/NO
5 / YES/NO
Date: / YES/NO
6 / YES/NO
Date: / YES/NO
7 / YES/NO
Date / YES/NO
8 / YES/NO
Date: / YES/NO
9 / YES/NO
Date: / YES/NO
10 / YES/NO
Date: / YES/NO

/10/10

CHD

Q1 – How do patients get on to the CHD register?

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Guidance:

Added at time of definitive CHD diagnosis (ie: MI, CABG)
New registration/summarisation of records (ie: past MI or CABG op)
Inpatient admissions
Outpatient investigations (ie: ETT/Angiogram)
Holding code may be used until a definitive diagnosis for CHD is reached (Read Code – 182- chest pain)

Q2 – How do you organise the follow-up of CHD patients

Guidance:

GP role
Opportunistic/Routine
Nurse role
At what stage referred to GP?
BP/Blood tests
Cholesterol
Uploading hospital information from admissions or regular outpatients review
Review of medication/Drug issues ie: Beta blockers, ACE, ARB, Antiplatelet
Flu Vaccination uptake

References; NICE, SIGN

Brown Book: pp 79 – 86

NICE: Appropriate use of Clopidogrel

SIGN: Diagnosis of Angina/Exercise tolerance testing

Cholesterol measurement/Statin use

Use of Antiplatelet drugs/Beta blockers

Visit Date………………………

CKD 2 – The % of patients on the CKD register who’s notes have a record of Blood Pressure in the previous 15 months

CKD 3 – The percentage of patients on the CKD register in whom the last blood pressure reading measured in the previous 15 months is 140/85 or less

Number / Computer. ID / Record of Blood Pressure in last 15 months / BP
Value recorded / Last recorded Blood Pressure (measured In the last 15 months) is 140/85 or less
1 / YES/NO
Date: / YES/NO
2 / YES/NO
Date: / YES/NO
3 / YES/NO
Date: / YES/NO
4 / YES/NO
Date: / YES/NO
5 / YES/NO
Date: / YES/NO
6 / YES/NO
Date: / YES/NO
7 / YES/NO
Date / YES/NO
8 / YES/NO
Date: / YES/NO
9 / YES/NO
Date: / YES/NO
10 / YES/NO
Date: / YES/NO

/10/10

Chronic Kidney Disease

Q1 – How do patients get on your CKD register?

Guidance:

Should mention US NKF CKD stages 3, 4,5; that is patients aged 18-years and over with eGFR of below < 60
Two tests should be done to confirm this result AT LEAST 3-months apart

Q2 – What factors do you consider in managing CKD patients?

Guidance:

BP. Be aware of lower BP target in CKD (140/85)
ACE/ARB usage

Visit Date…………………

COPD 10 - % of patients with COPD with a record of FeV1 In the previous 15 months

COPD 11- % of Patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked In the previous 15 months

Number / Computer. ID
COPD 10 / Record of FeV1 in the last 15 months / Computer ID
COPD 11 / Record of Inhaler technique checked in last 15 months
1 / YES/NO
Date: / YES/NO
Date:
2 / YES/NO
Date: / YES/NO
Date:
3 / YES/NO
Date: / YES/NO
Date:
4 / YES/NO
Date: / YES/NO
Date:
5 / YES/NO
Date: / YES/NO
Date:
6 / YES/NO
Date: / YES/NO
Date:
7 / YES/NO
Date: / YES/NO
Date:
8 / YES/NO
Date: / YES/NO
Date:
9 / YES/NO
Date: / YES/NO
Date:
10 / YES/NO
Date: / YES/NO
Date:

/10/10

COPD

Q1 – What factors make you consider COPD in a patient?

Guidance:

Symptoms of cough, sputum production and dyspnoea
Spirometry
NB. Approximately 15% of patients with COPD will also have Asthma; and patients with co-existing COPD and Asthma may be recorded on BOTH disease registers

Q2 – How do you organise Spirometry for your COPD register/potential COPD patients?

Guidance:

Spirometer in-house
GP role/Nurse Role and training
GOLD and BTS guidelines

Q3 – What difficulties do you encounter at managing COPD?

Guidance:

Compliance with annual review
Flu and Pneumonia vaccination uptake
Performing Spirometry in housebound patients
Smoking Cessation
Oximetry/LTOT
Knowledge of rehab service for COPD run by Sandy Walmsley
References: GOLD, BTS, NICE

Visit Date…………………

DM12 - % of patients with diabetes in whom the last blood pressure is 145/85 or less

DM13 - % of patients with diabetes who have a record of micro-albuminuria testing In the previous 15 months (exception reporting for patients with proteinuria)

Number / Computer. ID
DM12 / Record of blood pressure less than 145/85 / Computer ID
DM13 / Record of micro-albuminuria testing In the last 15 months
1 / YES/NO / YES/NO
Date:
2 / YES/NO / YES/NO
Date:
3 / YES/NO / YES/NO
Date:
4 / YES/NO / YES/NO
Date:
5 / YES/NO / YES/NO
Date:
6 / YES/NO / YES/NO
Date:
7 / YES/NO / YES/NO
Date:
8 / YES/NO / YES/NO
Date:
9 / YES/NO / YES/NO
Date:
10 / YES/NO / YES/NO
Date:

/10/10

Diabetes Mellitus

Q1 – How do patients get on to the Diabetes register?

Guidance:

Basis for diagnosis (random and fasting blood sugar/GTT)
Differentiating type 1/type 2 Diabetes
Does practice do GTT in-house or otherwise

Q2 – How do you organise follow-up of diabetes patients?

Guidance:

GP involvement
Nurse role
Periodic BP/blood and urine testing
Awareness of lower BP target in Diabetes
Retinopathy screening and linkage of information to clinical system
Diabetic foot check – vibration/sensation
Check done in house or in local clinic
References; NICE, BHS, SIGN

Visit Date………………………

BP 4 - % of patients with Hypertension in whom there is a record of the blood pressure in the previous nine months

BP 5 - % of patients with Hypertension in whom the last blood pressure (measured In the previous 9 months) is 150/90 or less

Number / Computer. ID / Record of Blood Pressure in last 9 months / BP
Value recorded / Last recorded Blood Pressure (measured In the last 9 months) is 150/90 or less
1 / YES/NO
Date: / YES/NO
2 / YES/NO
Date: / YES/NO
3 / YES/NO
Date: / YES/NO
4 / YES/NO
Date: / YES/NO
5 / YES/NO
Date: / YES/NO
6 / YES/NO
Date: / YES/NO
7 / YES/NO
Date / YES/NO
8 / YES/NO
Date: / YES/NO
9 / YES/NO
Date: / YES/NO
10 / YES/NO
Date: / YES/NO

/10/10

Hypertension

Q1 – How do patients get on to the Hypertension register?

Q2 – How might you manage a Blood pressure value greater than > 150/90?

Guidance:

Action plan, repeat BP readings
Lifestyle issues. Weight, exercise, smoking etc
Drug issues
Compliance, how do you assess this?
Awareness of different BP target levels recommended for Diabetes and CKD

References: BHS

Mental Health
MH 9. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status (40-90%)
No / Comp. ID / Date of mental Health Review + who did it
MH9 / Alcohol and drug issues
MH 9 / Cervical screening
(if appropriate)
MH9 / BP – current value & date of reading
MH 9 / Smoking status recorded
MH 9 / Smoking Cessation advice given
MH 9
1
2
3
4
5
6
7
8
9
10

Mental Health

Q1 – How do you decide which patients to include on your Mental Health register?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Guidance: Only if diagnosis of Schizophrenia, Bipolar Affective Disorder or any Psychotic episode

Q2 – How do you manage your patients on Lithium?

Guidance:Should mention process for identifying Lithium taking patients

Methods for checking appropriate blood tests have been done
Lithium levels should be checked a minimum of 6-monthly in stable patients
U&E’s/TFT’s should be done at least annually as 15% of Lithium taking patients become Hypothyroid

Q3 – What areas do you cover in your annual review of patients on the MH register?

Guidance:

Physical checks/routine health promotion (BP etc)
Should mention appropriate preventative medicine (eg smoking status, alcohol consumption, cervical smears (uptake low), appropriate blood tests eg cholesterol, blood sugar if on olanzapine or risperidone)
Support network for patient/carer
Relapse planning including early warning signs of relapse, should be done in discussion with patient when patient is well
Interaction with secondary care and what services are received

If under secondary care, copy of CPA suitable for items 3,4 and 5

Q4 – Do you have any patients on depot neuroleptic medication? If so what do you do if they DNA for an appointment?

The answer should indicate trying to contact the patient, and if under secondary care, notify the key worker of any concerns that you may have
References; NICE

Visit Date…………………

Smoking 3 - % of patients with any or any combination of the following conditions: CHD, Stroke or TIA, Hypertension, Diabetes, COPD, CKD, Asthma, Schizophrenia, Bipolar affective disorder, or other psychoses whose notes record smoking status in the previous 15 months

Smoking 4 - % of patients with any or any combination of the following conditions: CHD, Stroke or TIA, Hypertension, Diabetes, COPD, CKD, Asthma, Schizophrenia, Bipolar affective disorder, or other psychoses who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months

Number / Computer. ID / Smokingstatus recorded in the last 15 months / Computer ID / Smoking
Cessation advice or referral recorded
1 / YES/NO
Date: / YES/NO
Date:
2 / YES/NO
Date: / YES/NO
Date:
3 / YES/NO
Date: / YES/NO
Date:
4 / YES/NO
Date: / YES/NO
Date:
5 / YES/NO
Date: / YES/NO
Date:
6 / YES/NO
Date: / YES/NO
Date:
7 / YES/NO
Date: / YES/NO
Date:
8 / YES/NO
Date: / YES/NO
Date:
9 / YES/NO
Date: / YES/NO
Date:
10 / YES/NO
Date: / YES/NO
Date:

Warfarin

Question / Comment / Guidance
How are repeat prescription requests for warfarin processed? / Ensure that before issuing a repeat prescription for warfarin that the patient’s INR is being monitored regularly and that it is at a safe level for the repeat prescription to be
issued. The easiest way to do this is to ask to see the patient-held INR record, e.g. anticoagulant yellow book.
Ideally, repeat requests for warfarin prescriptions should be raised as an acute prescription by the prescriber and not processed in the same way as any other repeat prescription request.
Do you have records of training of all members of staff who are involved in the management of patients on anticoagulant therapy? / Ensure that all surgery staff caring for patients on anticoagulant therapy have the necessary work competences commensurate with their role in that process. This includes GPs, practice nurses, practice pharmacists and receptionists. To help with this, the NPSA has developed a series of
workforce competence statements and two elearning modules, as listed below:
Workforce competence statements:

initiating anticoagulant therapy;

maintaining oral anticoagulant therapy;

reviewing the safety and effectiveness of an anticoagulant service.

e-learning modules:

starting patients on anticoagulants;

maintaining patients on anticoagulant therapy

How do you check patients recently initiated on warfarin therapy have received appropriate information? / Ensure that patients on anticoagulant therapy have received appropriate verbal and written information at the start of their therapy, and when necessary throughout their treatment. In practice, this means making sure that patients have received a ‘yellow book’ and ensuring that they (or their carers) fully understand its contents.
How is the dose in the patient’s warfarin yellow book expressed? / Doses in the patient’s warfarin yellow book should include the dose expressed in milligrams (mg).
This may be supplemented by additional advice/leaflets.
How is the dose of warfarin on the patient’s prescription expressed? / Doses of warfarin on the prescriptions should not be expressed as a specific dose or “as directed.” The patient’s anticoagulant yellow book will have the most up to date dose written in it this should be expressed as “as directed by the anticoagulant yellow book”
What is the normal quantity of warfarin prescribed? / Warfarin should be prescribed in multiples of 28 to ensure that it is dispensed, by the pharmacist, in original containers with a patient information leaflet. Warfarin is available in packs of 28 which are often colour coded to match the tablets. Therefore, if different quantities are prescribed tablets must be packed in generic white cartons or are dispensed from bulk packs in to brown bottles making it more difficult for the patient to identify different strengths.
Have you carried out an annual audit on warfarin services? / Carrying out an annual audit is part of the NPSA alert guidance for GPs.
Education 1 (4 Points)
There is a record of all practice employed clinical staff having attended training/updating in basic life support skills in the preceding 18 months
Written Evidence required: Attendance at BLS training should be listed (or this may be in the form of certificates of attendance)
Assessors Guidance: Assessors should confirm by checking the BLS attendance list (or certificates) that Practice employed clinical staff have all attended. It may be sufficient forone individual In the team to attend for external training and then cascade this within the team. If this is the case then the team should be questioned about their attendance at the Training within the Practice.
Indicator aspired to / Y/N
Clinical staff
(e.g. GP, Nurse, HCA) / Date Attended / Evidence seen / Comments
Indicator / Management 10 (4 Point)
Narrative / There is a written procedure manual that includes staff employment policies, including equal opportunities, bullying and harassment and sickness absence (including illegal drugs, alcohol and stress), to which staff have access
Assessor Guidance / It is acceptable for the Practice to have individual policies for these areas or they may be contained within one large folder of employment policies. It may contain one date of review for all policies or they may be marked individually. The important thing is that the Practice have them, review them and that staff are aware of how to access them.
Standard of Policy / Yes / No
Title
Aim
Responsibility
Procedure
Implementation & Review Date
Assessment of Implementation / Are the staff aware of :
The content of these policies?
Where these policies are kept in the Practice should they need to consult them for any reason?
Policies included
Equal Opportunities Policy
Bullying and Harassment
Sickness absence
Disciplinary and Grievance Procedure
Indicator Achieved
Recommendations
Medicines 2 (2 Points)
The Practice possesses the equipment and in date emergency drugs to treat anaphylaxis
Written Evidence required: There is a list of equipment and drugs that the Practice has available to deal with an anaphylactic emergency
Assessment Visit: The appropriate drugs and equipment are inspected.
Assessors Guidance: The dates of emergency drugs should be checked. You will likely see hydrocortisone, piriton and adrenalin
Indicator aspired to / Y/N
Indicator achieved / Y/N
Are all of the drugs checked within date? / Y/N
Are the Practice using 1:1000 adrenaline?
Comments:
Medicines 3 (2 Points)
There is a system for checking the expiry dates of emergency drugs on at least an annual basis
Assessment Visit: A random sample of doctors bags and other emergency drugs is checked
Assessors Guidance: All drugs should be in date and the doctors should be questioned on the system for keeping them all up to date.
Aspired to: Y/N
Indicator Achieved: Y/N
What systems are in place to ensure their emergency drugs do not go out of date?:
How often is this check carried out?
Medicines 4 and 8 (2 Points)
Med 4 - The number of hours from requesting a prescription to availability for collection by the patient is 72 hours or less
Med 8 -The number of hours from requesting a prescription to availability for collection by the patient is 48 hours or less
Written Evidence required: The Practice Leaflet or policy should be checked. Details of how the Practices system works should be described in the leaflet. The receptionists are questioned on the policy
Assessors Guidance: The assessors should check that the system for issuing repeat prescriptions can be described by the receptionists and should observe it in action
Aspired to:
Meds 4 Y/N
Meds 8 Y/N
Indicator Achieved:
Meds 4 Y/N
Meds 8 Y/N
Is the prescription/repeat prescription available to pick up in 72 hours or less?
Is the Prescription/repeat prescription available to pick up in 48 hours or less?
Are the details for the process contained In the Practice Leaflet?

Qualifications of performers

Clause 340. Subject to clause 341, no medical practitioner shall perform medical services under the Contract unless he is-
340.1 included in a medical performers list for a Primary Care Trust in England;
340.2 not suspended from that list or from the Medical Register; and
340.3 not subject to interim suspension under section 41A of the Medical Act 1983. / Are all of the medical practitioners within the practice currently included In the medical performers list?
What is the Practice process for checking the performers list inclusion for new performers? / Practices should be asking new performers which list they are included on. It is not appropriate for them just to see a letter of inclusion from a PCT as this letter may be out of date, they should telephone the relevant PCO to check. Solihull issued a checklist 2 years ago for this process.
Clause 342. No health care professional other than one to whom clauses 340 and 341 apply shall perform clinical services under the Contract unless he is registered with his relevant professional body and his registration is not currently suspended. / Do all health care professionals hold current registration with a relevant professional body?
What is the process for checking the relevant memberships?
Do the Practice check that registration is not suspended? / Nurses Professional Body is the nursing and midwifery council. HCA’s are not required to join.
Conditions for employment and engagement
Clause 351. The Contractor shall not employ or engage a health care professional to perform medical services under the Contract unless-
351.1 that person has provided two clinical references, relating to two recent posts (which may include any current post) as a health care professional which lasted for three months without a significant break, or where this is not possible, a full explanation and alternative referees; and
351.2 the Contractor has checked and is satisfied with the references. / Do the Practice ask for references when employing a new Doctor?
Do the Practice ask for references when employing a locum? / New health care professionals should provide two clinical references, relating to two recent posts (which may include any current post) as a health care professional which lasted for three months without a significant break, or where this is not possible, a full explanation and alternative referees

Schedule 9