QOF Accident and Emergency Indicators QP12-QP14

The QOF quality and productivity (QP) accident and emergency (A&E) indicators have been introduced for one year from April 2012 and are aimed at reducing avoidable A&E attendances. These indicators replace the 2011/12 QP indicators on prescribing (QP1, QP2, QP3, QP4 and QP5).

To ensure prescribing improvements continue, NHS Employers and GPC negotiators have agreed the following:

“Although the prescribing element of the quality and productivity scheme will be replaced with A&E attendances in 2012/13, we agree that all practices in the UK should continue to ensure cost effective prescribing when compared to peers, building on the progress achieved in 2011/12. Those practices who remain significant outliers would also be expected to continue to participate in external peer review during 2012/13.”

As with the outpatient referrals (QP6 and QP7) and emergency admissions (QP9 and QP10) indicators, the A&E attendances indicators (QP12 and QP13) require that a practice undertake an internal review followed by an external peer review.

Internal review (QP12)

PCOs are required to supply practices with data from the final quarter of the 2011/12 year (1 January to 31 March 2012) on A&E attendances which the practices reasonably require to conduct the review. The data should, where possible, include patient details, reasons for attendance/diagnosis and the time/date of the attendance. In order to assist PCOs in supplying the relevant information to a practice it may be helpful for the practice and PCO to initially discuss what data is available and how the PCO will supply the relevant information. In doing this both the practice and PCO will be clear about the expectations regarding the level of data available and when it will be supplied.

If for whatever reason a PCO is unable to provide the data within a reasonable timeframe that allows practices to meet the indicator deadlines, then it is expected that the PCO will allow practices a longer timeline to complete the review. In such circumstances a decision to allow a longer timeline should be determined locally and clearly agreed between the PCO and practices. Practices may wish to reference this in their reports to the PCO for each of the indicators. Any disputes that may arise as a result of this should be handled through the normal dispute resolution procedures.

Scotland

In Scotland, if data is not available to allow for the internal review to take place by 30 June 2012, then practices will have eight weeks within receipt of the data in which to hold the internal review.

The definition of ‘avoidable attendances’ should be defined by the practice and agreed with the PCO prior to reviewing the data.

Attendances at A&E are defined as those patients seen in a Type 1 A&E department for both first and follow-up attendances for the same condition. Attendances should not include those that are planned or planned follow ups. For example:

  • where a patient has had a prior consultation with their GP for a condition that clearly requires A&E attendance and the GP informs A&E of the impending attendance (e.g. access to specialist/urgent diagnostics/assessment such as an x-ray for suspected fractures and/or admission)
  • where the A&E has booked a follow up appointment.
  • if a patient attends the department due to it being where their registered practice is seeing their patients.
  • if it is the agreed place for a patient to be seen prior to admission.

The definition in the document A&E Clinical Quality Indicators Data Definitions published by the Department of Health in England defines a Type 1 A&E department as “a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients”.

In circumstances where there is no Type 1 A&E department or where the majority of patients do not use a Type 1 A&E department, then practices and PCOs should agree the most frequently used local urgent care service and agree those that will be included (for example Type 2 and/or Type 3 A&E departments). The type of A&E attendance will be limited to both first and follow-up attendances for the same condition (excluding planned follow-ups).

Scotland

In Scotland - the principle of focusing on Type 1 A and E where appropriate and thereafter on the most frequently used local urgent care service should be applied .

For Rural Health Boards where the National QOF QP Framework may not easily apply, local flexibility should apply and where appropriate should be agreed between the Health Board and the LMC. Where agreement between the Health Board and the LMC is not reached, for whatever reason, then the Scottish Government Health Department and Scottish GPC will decide jointly. The Scottish Government will support individual boards to identify areas of action where there are no AE attendances.

Further information:

The internal review should take place at least once prior to 31 July 2012, or an agreed later date if the data is not made available, with the range of clinicians working in the practice. At the meeting the practice will explore the reasons for registered patients’ attendance(s) at A&E, identifying any emerging patterns and discussing this with reference to available care pathways and the capability and access within primary care services to see and treat patients.

In the discussion, focus should be given to:

  1. Older patients with co-morbidities at high risk of admission (patients aged 65 years and over).
  1. Children with minor illness/injury (patients aged 15 years and under).
  1. Patients who frequently re-attend A&E that could be dealt with in primary care.

The review should also specifically consider whether same day access to clinicians in the practice is appropriate and whether any comparisons can be drawn between this and the level of A&E attendances.

The output of the review must be made available to the group of practices taking part in the external peer review meeting (QP13).

Practices are required to produce and submit a report to the PCO no later than 31 July 2012. It is advised that the report should include the following information:

  • date of meeting and people in attendance
  • a summary of the discussions that took place at the meeting
  • information on what, if any, comparisons have been drawn between same day access to clinicians in the practice and the level of A&E attendances
  • information on the practice’s current access arrangements
  • how the practice defined ‘avoidable attendances’.

Practices may wish to include information for discussion at the external peer review meeting on where improvements may be made to improve the quality of care for patients at the interface of primary care and A&E, in order to help reduce avoidable A&E attendances.

In developing the final report, practices may find it useful to refer to the Primary Care Foundation Report Urgent Care - A Practical Guide to Reforming Same Day Care in General Practice published in 2009. The report is available at:

External peer review (QP13)

The external peer review group must consist of a minimum of six practices. A group may only be made up of less than six practices if agreed with the PCO, taking into account local geography and historical groups of practices. Where possible the practices should have similar care pathways and/or geographical locations. The group may be the same as that used for the other QP indicators.

At the meeting each practice should be represented by at least one GP. During the external peer review practices should compare their practice data with comparable data from practices in the group, or all practices in the PCO area, to determine why there are any variances and where it may be appropriate to amend current arrangements to help reduce avoidable A&E attendances. The focus of the review will be to reflect on the reasons and/or patterns of A&E attendances and identify where improvements may be made to improve the quality of care for patients at the interface of primary care and A&E, in order to help reduce avoidable A&E attendances. Focus should be given to:

  1. Older patients with co-morbidities at high risk of admission (patients aged 65 years and over).
  2. Children with minor illness/injury (patients aged 15 years and under).
  3. Patients who frequently re-attend A&E that could be dealt with in primary care.

Practices may also propose, via the peer group, areas for commissioning or service design improvements to the PCOs that could help reduce avoidable A&E attendances.

Following the review, the practice improvement plan is either amended or agreed by the group.

Practices are required to produce and submit a report to the PCO by no later than 30 September 2012. The report should include the following information:

  • date of meeting and details of practices in attendance
  • a summary of the discussions that took place at the meeting
  • details of the agreed improvement plan that aims reduce avoidable A&E attendances.

Scotland

For Scottish practices the practice groupings will be agreed between the Health Board and the Local Medical Committee (LMC). The report must be submitted to the Health Board by no later than 15 March 2013.

Implementation of improvement plan (QP14)

Practices will be required to implement the arrangements and actions set out in their improvement plans agreed in QP13. In doing this practices will need to review their monthly data to provide information on how improvements in care and primary care access have been made. The report should include information about (1) older patients with co-morbidities at high risk of admission, (2) children with minor illness/injury and (3) patients who frequently re-attend A&E, as well as how any improvements in care and access in primary care have helped to reduce avoidable A&E attendances. If the data quality provided to the practice does not allow this to be done for all patients, this should be noted in the report.

Evidence to support implementation will be provided to the PCO in the form of a report by no later than 31 March 2013. The report should include the following information:

  • a summary of the details of the improvement plan
  • the action taken to help reduce avoidable A&E attendances
  • information on the three categories of patients (see above) and how improvements in care and primary care access have helped reduce avoidable A&E attendance for these patients.

If the data quality provided to the practice does not allow this to be done for all patients, then this should be noted in the report with an explanation as to which patients the data are missing and, if possible, the reasons why.

See page 8 for guidance on end of year report.

Scotland

The end of year evidence required for Scotland will include the following:

1. Older patients with co-morbidities at high risk of admission (patients aged 65 years and over) - care plan for high risk SPARRA patients (1/2500 registered list size)

Description of case review to include:

  • Internal Practice issues required to support reducing attendance
  • External to practice eg Social work, Secondary care issues required to support reducing attendance
  • Any other issues/learning

2. . Children with minor illness/injury (patients aged 15 years and under)

Plan describing measures to reduce avoidable AE attendances by this group to include:

  • Internal Practice issues required to support reducing attendance
  • External to practice eg Social work, Secondary care issues required to support reducing attendance
  • Any other issues/learning

3. Patients who frequently re-attend A&E that could be dealt with in primary care

Description of case review to include:

  • Internal Practice issues required to support reducing attendance
  • External to practice eg Social work, Secondary care issues required to support reducing attendance
  • Any other issues/learning

4. For men of working age in practices with no patients in 1 and 3

Plan describing measures to reduce avoidable attendances in A and E to include:

  • Internal Practice issues required to support reducing attendance
  • External to practice eg Social work, Secondary care issues required to support reducing attendance

Any other issues/learning
APPENDIX A

Care Plan

Some care plans are mainly for community or hospital staff to highlight the best way to treat a patient if they attend. Other care plans will be mainly to inform patients of how best to access the advice or treatment they need when they feel unwell.

The areas below will not all need to be included in every care plan; it is up to the author of the plan to pick and choose what is best for their patient.

The plan may be written by a GP or by another clinician who is involved with the patient for example a CPN or practice nurse

  • Patient details
  • GP details
  • Details of any other staff or support/community agencies involved. Other groups e.g. Community Learning Disability Teams, Mental Health Teams, Social work or housing may be detailed here.
  • Details of any other family, friends or support staff willing to be contacted if the patient attends A+E (both in and out of hours)
  • Diagnosis

Any significant diagnosis and operations the patient has had. It can be helpful to detail a patients normal presentation or usual symptoms to help guide a clinician who may be unfamiliar with the patient. In certain conditions it can be useful to list their normal baseline observations e.g. COPD and oxygen saturations.

  • Medication – normally accessed through ECS but note any specific medication issues eg avoid opiates
  • Investigations

Some patients have had lots of negative investigations over the years which can be helpful to list as it may avoid these being repeated unnecessarily.

  • Background

If appropriate document where they live, who they live with. Any significant past medical or social history. Also any details of where they get their support from and who they are closest to. It can be helpful to list any particular stressors that may make it more likely for a patient to seek help.

  • Guidance for patient

If a patient has a copy of the plan it can be useful to highlight what steps they can take before attending either their GP or AE.

This can be written by another team involved with them CLDT, Mental Health.

It can list the best person to contact in certain situations and this might not always be health centres e.g. pharmacy, voluntary agencies, support staff who work with them.

  • Guidance during consultation

This is usually for the emergency department staff when they see the patient.

It may be medical and drawn up in conjunction with secondary care.

It may involve a description of their usual presentation or usual baseline obs (oxygen saturation etc).

Or it may be based around their ability to read or understand or may be advice on how they interact with staff.

If there are any concerns about them being seen alone or by a particular sex then that should be recorded in this section.

Phrases that are used for patients with somatising or abnormal health seeking behaviour are

  • Treat the signs not the symptoms
  • Aim is to de-medicalise the problem
  • Aim is to reduce possibility of iatrogenic harm through over investigation
  • Please do not speculate on possible diagnosis

SUGGESTED PROCESS

Step 1: Draw up Plan

Step 2: Discuss with patient

Step 3:Review patients co-operation with the plan

Step 4: Further meeting if required.

Once a care plan is in place in some patients it is necessary to agree a contract with them and to review this after a few months. It may state that they do not attend AE for minor injuries but use a different path specified in the plan. If they do not meet these requirements then the practice could suggest a further meeting maybe with secondary care input to best plan a way forward.

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