Master Copy – date: 03/12//07
Developing General Practice in Shropshire County PCT through a Balanced Scorecard approach (GMS)
1.0 Introduction
The PCT and independent contractors share a common interest in ensuring that primary care services are easily available to its residents and that they are of the highest quality. A shared commitment to ensure that as much care as appropriately possible takes place in non-acute settings gives added impetus to the further development of primary care.
Additionally, the 2005 NHS Policy Commissioning a Patient Led NHS places clear responsibilities on PCTs as commissioners of services. It is clear that a robust focus on commissioning is required, ensuring that services are appropriately identified, commissioned and performance-managed by PCTs. This applies equally to all providers whether they are independent contractors, NHS Trusts or organisations from the mutual, independent or private sectors.
The Healthcare Commission has now clarified the extent to which its standards also apply to independent contractors, and has signalled that for 2006-07 it will take a special interest in assessing how PCTs as commissioners achieve assured compliance from independent contractors with their standards.
Within this context of PCTs now being required to commission and performance manage primary care, it is clear that a number of useful performance indicators, including for example those associated with the Quality and Outcomes Framework (QOF), Local Enhanced Services & their component parts, patient experience surveys and premises reports, exist to support this function.
In addition, nowhere is this information systematically made available to patients, with the PCT instead being subject to random Freedom of Information (FOI) requests.
This tool has therefore been adopted by West Midlands Strategic Health Authority and adapted locally, to bring these indicators together, setting out minimum acceptable standards and the PCT’s approach to improving standards. It is intended that these quality indicators and the assessment of practices will be public information. For new additional capacity, whether with Alternative Providers of Medical Service (APMS) Personal Medical Services (PMS) or General Medical Services (nGMS), the PCT will seek to commission at the highest level of performance taking a more developmental approach with existing contractors who fall below the minimum standards.
2.0 The PCT’s Approach
The PCT acknowledges that there are many elements of primary care within Shropshire County that are truly excellent and it would wish to support the development of these further.
The balanced scorecard provides a systematic approach to assessing each practice and where desirable follows each assessment with the deployment of an agreed range of interventions aimed at raising standards. In many ways it therefore formalises and makes existing arrangements more transparent.
It is intended that this process will be formally launched in spring 2007, with support available to enable practices to gain a full understanding of the process and indicators.
The PCT aims to ensure that the completion of the balanced scorecard is not onerous, and that it is achieved relatively quickly, with little effort required by practices. The PCT already collects a large amount of information about practices and will collate this into an initial assessment. The relevant PCT Primary Care staff will then visit the practice to assist with the completion and validation of the assessment.
The scorecard is divided into two parts.
Part A focuses on mandatory elements with which all GP practices should comply, which include the Healthcare Standards and contractual requirements of the nGMS Contract. The information collected and results achieved will be available in the public domain.
Part B is made up of developmental elements, which include prescribing, childhood immunisations and QOF. The results relating to this part of the scorecard will not be made available in the public domain.
Each indicator is subject to ongoing change and development over the years, subject to experience in its application. Over time, it may be that new indicators replace ones that have become less relevant.
Following assessment, the PCT will meet to consider the reports and appropriate actions and milestones will be developed with practices that are struggling to meet acceptable standards. There will be a focus particularly on areas that are scored in the lowest level of achievement, i.e. below acceptable minimum standards of practice.
There will be opportunity for practices to comment on the assessment and the PCT will discuss with each practice how to address any issues
The basic intention of the Balanced Scorecard is to identify where good patient care is being achieved and where there is evidence of continuous improvement. In practices where this cannot be evidenced and where the PCT’s formative and facilitative approach results in either lack of cooperation for improvement or lack of progress, then the PCT will need to use its commissioning powers to request improvement.
It should be noted however that the PCT’s overall aim is the improvement of primary care services.
57
Master Copy – date: 03/12//07
3.0 The Balanced Scorecard – an overview
The balanced scorecard focuses on the assessment of the following areas of primary care delivery (Indicators):
PART A
A 1 Compliance with Healthcare Commission Core Standards
A 2 Statutory contractual requirements as set out in the nGMS (PMS) regulations as amended
A 3 Environment (i.e. premises, buildings) and infection control
A 4 Access to and availability of medical services performed under the medical services regulations
A4.1 Registration
A4.2 Access to medical services
A4.3 National access measures – PCAS
A 5 Delivery of Essential and Additional Services
A 6 Business Continuity Plan
A 7 Quality & Outcomes Framework (QOF)
A 8 Public Health areas
A 8.1 Cervical screening
A 8.2 Childhood immunisations
A 8.3 Influenza and pneumococcal vaccinations
PART B
B 1 Access to and availability of medical services performed under the medical services regulations
B 1.1 Supply of clinical staff – sessions
B 1.2 Supply of clinical staff – appointments
B 2 Telephone access
B 3 The clinical and cost effectiveness of prescribing
B 4 Patient views
B 4.1 QOF patient satisfaction survey (GPAQ/IPQ)
B 4.2 Processes for acting upon patient views
B 4.3 Patient Experience Survey (Access DES)
B 5 Patient services
B 5.1 Choose and Book
B 5.2 IM & T
PART C
C 6 Care Coordination Centre
Measuring System
Under each main heading there are a series of quality indicators, each with a rating banding A, B or C, with the following meaning:
Band A / Meets or exceeds the minimum standardBand B / Meets the minimum standard
Band C / Does not meet the minimum standard – remedial action required
In the setting of standards the PCT has attempted to select criterion-referenced (or absolute) standards rather than peer-referenced standards. This should maximise transparency and minimise the need for appeal. Standards are linked to the requirements of the nGMS and PMS Contracts and associated NHS Regulations and to other key NHS quality standards.
Each indicator will receive an A, B or C rating, and a practice will receive a list of all of its ratings for all indicators. These will not be aggregated into a single assessment, but will be totalled, such that at a glance it will easy to ascertain, for example, that out of 30 indicators, Practice X has 14 Band As, 10 Band Bs and 6 Band Cs.
The summary sheets for Part A and Part B are shown in Appendix 1 and Appendix 2 respectively.
Whilst the PCT is keen to encourage all its practices to score Band A for all indicators, its development energy and commissioning powers will inevitably be focused on practices with Band C scores, prioritising those with most band Cs.
57
Master Copy – date: 03/12//07
PART A
Indicators to be measured – PART A (Mandatory)
A brief description of the indicators for part A is detailed below and correlates to the summary sheet at Appendix 1.
4.1 Compliance with Healthcare Commission (HCC) Standards
The Healthcare Commission’s Core Standards are set out at Appendix 3. They apply to all providers of healthcare in England, and all healthcare organisations (PCTs, Mental Health Trusts, Hospital Trusts) have been asked to declare compliance with the Core Standards through the Annual Health Check from April 2005. From April 2006, PCTs are responsible for ensuring that independent contractors meet the Healthcare Commission Core Standards.
Whilst it is recognised by the Healthcare Commission and the PCT that the standards may be onerous for smaller providers, it should also be realised that regardless of practice size patients are entitled to good care. Where possible in link areas where work is already established or underway (such as QOF domains) these have been highlighted in order to prompt areas where work already undertaken can be built on.
The aim is full compliance with these comprehensive and established standards, but for this year we are proposing a developmental approach as follows.
There are 24 core standards, 2 of which are not applicable to general practice. The remaining 22 HCC standards are broken down into several prompts, each of which will be scored as follows:
Level 1 / The practice can demonstrate that the standard is being met and that acceptable evidence can be producedLevel 2 / The practice is aware of the standard and is currently working towards meeting it.
Level 3 / The practice does not currently meet this standard and has not started to work towards this.
The total score for a practice will then be translated by the PCT into a Band, as follows:
BANDING / CRITERIA COMMENSURATE WITH GRADINGA / Practices achieving 82% and above of assessment requirements at level 1 (³ 18 indicators at level 1)
B / Practices achieving 64%-77% of assessment requirements at level 1
(14-17 indicators at level 1)
C / Practices achieving less than 64% of assessment requirements at level 1 ( 14 indicators at level 1)
A 2 Contractual and statutory requirements
The nGMS and PMS contracts allow for a variety of basic standards, such as each practice having an up to date practice leaflet, each one having a compliant complaints procedure, conforming to the Data Protection Act, etc. A full list of requirements is appended at Appendix 4.
For the purposes of banding, it is proposed that any Practice not delivering basic contractual requirements and which is incapable of remedy within 12 weeks of assessment shall be banded Band C for this section.
Complying with nGMS and PMS Contracts and associated statutory regulations is an absolute requirement, and therefore only two bandings will be available for this standard:
Band A / Fully compliantBand C / Not compliant
A 3 Environment (i.e. buildings), and Infection Control
The full requirements for standards pertaining to premises, as noted in the nGMS and PMS contract, are contained in Appendix 5. The Banding for this standard is as follows:
Band A / Fully compliantBand B / Fully compliant on all but two areas, both of which are capable of remedy
Band C / Not compliant with all minimum standards, or with breaches not capable of remedy
In addition, the PCT from time to time undertakes an infection control audit of primary care premises. It is proposed that any practice that has outstanding actions following an infection control audit that are not remedied within 2 weeks, shall be banded band C for this section.
The Estates Department at the PCT would be responsible for this indicator where the building is owned or managed by the PCT.
A 4 Access and supply of medical services
The National patient survey has indicated that most comments from patients regard access and supply of medical services as a high priority in relation to their satisfaction. Accordingly, for the foreseeable future, this area is accorded special weight. Patients want to see choice available in primary care and will wish to exercise their right to register with a practice able to provide them with their healthcare needs.
It is proposed that the following areas are assessed:
§ Registration (Part A4.1)
§ Access to medical services (Part A4.2)
§ Supply of Clinical Staff (Part B1)
§ National Access Measures (Part B4.3 – if undertaking Access DES)
§ Telephone Access (Part B2)
A 4.1 Registration
The regulations around the registration of a patient who lives within the agreed and contracted practice boundary area are clear. Therefore there are only two bandings for this standard.
Band A / Practices fully complying with contractual registration requirementsBand C / Those practices not complying with registration requirements through being ‘open but full’, setting a cap for list size, only registering certain types of patients, refusing to register patients wishing to change practice or operating a waiting list.
A 4.2 Access to Medical Services
The contractual regulations define core hours as: “Monday to Friday 8.00 am to 6.30 pm except Good Friday, Christmas Day and Bank Holidays”.
A contractor must provide primary medical services during core hours as are appropriate to meet the reasonable needs of its patients and have in place arrangements for its patients to access such services throughout the core hours in case of emergency. The practice must inform patients of opening hours and the method of obtaining access to services throughout the core hours. (See Appendix 4 ‘Essential Services’).
Practices offering extended hours are those offering hours of opening for appointments beyond those stipulated in the national contract and for this reason are banded in Band A.
It is proposed therefore that the following banding will apply to opening hours:
Band A / Open for core hours and offers some extended hours and has clear cover arrangements in place for when the surgery is closed.Band B / Offers core hours and has clear cover arrangements in place for when the surgery is closed during core hours.
Band C / Opening times are unclear, less than core, or has unclear cover arrangements in place for when the surgery is closed, or has opening hours subject to contractor variation without agreement of the PCT.
A 4.3 National Access measures
The Directed Enhanced Service (DES) for Access supports the ongoing commitment to ensure excellent access to medical services. The regular Primary Care Access Survey (PCAS) assess the extent to which patients can book a routine appointment in advance to see a GP within 48 hours and Primary Health Care Professional within 24 hours. It is proposed that the following banding applies to practice performance as assessed by the regular PCAS survey: