Shared learning database

NHS Kent and Medway
Published date:
January 2012

Producing QOF style business rulesets for NICE guidelines allows the systematic deployment and monitoring of NICE guidelines in primary care.

Adding QOF style prompts to support adherence to the guidelines produces further benefits to patient care.

Being able to run this across a PCT/CCG.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To improve patient care and outcomes by increasing the uptake of and adherence to NICE guidelines in primary care. To be able to systematically deploy and monitor NICE guidelines in primary care across a PCT / CCG.

To have agreed business rulesets that allow direct comparisons of adherence to NICE guidelines between practices and PCTs/CCGs.

To make this work without additional workload falling on the practices in running audits or reports helping them to work smarter not harder.

To make this work without additional workload falling on the clinicians, don't make the clinicians look up the guidelines make the guidelines come to the clinician, individualised for each patient the clinician sees and dependant on that patients needs.

Reasons for implementing your project

NICE guidelines didn't come with business rulesets or in some cases the necessary Read Codes for them to be effective and monitored in a primary care setting.

Uptake in primary care is currently ad hoc with no systematic monitoring or support generally relying on the individual clinician to get it right.

Clinicians needed in a 10 minute GP consultation to remember all the current NICE guidelines work out which ones are applicable to that individual patient apply the guidance and record it in a way that would be auditable.

It's a very difficult task, clinicians want to practice good medicine but it's difficult so we planned to make it easier.

How did you implement the project

We started writing audits based on NICE guidelines that could run in primary care. Where necessary we requested Read Codes necessary to implement or monitor the uptake of the guideline in primary care.

We licensed software that would allow us to deploy audits across all GP IT systems (except system one/TPP) which could add QOF style prompts into the clinical system to remind the clinician to follow the NICE guidance that was applicable to that individual patient based on all the information that the GP IT system currently held for that patient.

The use of prompts to remind the clinician which piece of NICE guidance is applicable to that individual patient at that point in time MAKES IT EASIER to follow the guidance and provide better care.

In the same way that most people now use a satellite navigation system when they're driving somewhere their not familiar with reminding what to do next this approach provides a clinical support system advising the clinician of what to do next to better manage their patient.

It also provides business support to practices through daily reporting which lists patients who are due or have missed an intervention and to PCTs / CCGs weekly reporting (with no patient identifiable information) at practice level.

Key findings

The results of the audits can be monitored centrally.

In almost all audits we're seeing improved performance.

In Atrial Fibrillation in our CCG 275,000 patients we've over 71% of patients who have a CHADS2 score of 2 or above on warfarin with 4% coded as refusing warfarin treatment or warfarin being contraindicated.

We've screened for alcohol usage using the AUDIT C and AUDIT questionnaires an additional 15,000 patients in the last year, now over 11% of the adult population, increasing month on month. This still ridiculously low compared to the 82% of adult patients we've a smoking history recorded on. We see no reason why the level of screening for BMI and alcohol usage, and the provision of appropriate advice or support services shouldn't be over 80% as it is for tobacco usage.

We've increased the prevalence of patients recorded as having Familial Hypercholesterolaemia or Possible Familial Hypercholesterolaemia (a new Read Code we requested) as diagnosed using the Simon Broome criteria.

We've also audits for COPD, Heart Failure, CKD, Hypertension, Lithium monitoring (NPSA), Tobacco, Alcohol, BMI, Learning disability, prevalence, niche audits to support better management of rare conditions that because of their rarity are both unlikely to prioritised by NICE or included in QOF, and audits to support screening programmes.

If we come across anything that could help a practising clinician do a better job for the patient they're consulting with by helping them remember what they should be doing for that individual patient at that particular point in time we'll try to write an audit to help.
,/br> This is a long term project which helps clinicians in primary care do a better job and helps CCG's identify variations in care given between practices and target support.

Some clinicians use this more than others and some practices use this more than others, but without any additional payments to practices we're showing improvements in care.

Key learning points

If your job is more difficult than it should be find a solution. If the people you think should be solving the problem aren't or won't do it, you've still got a problem. Find another solution DONT GIVE UP.

Software exists to deploy audits, add prompts and monitor the results. Look at what's already available before trying to design something yourself.

We've written audits to monitor a range of clinical conditions based on NICE guidelines, some are better than others and we're refining those that cold be better. Look at what's already available before trying to design something yourself.

Data extraction systems only tell you what you should have done but didn't. The addition of prompts helps you do the right thing at the right time for the right patient, get it right first time. Prompts work.

Clinicians want to practice good medicine this makes it easier for clinicians to do what they want to do.

The evidence is in QOF many practices deliver care exceeding the upper limits for QOF payments they're doing things because it's good for the patient even though they're no longer being paid to do it.

This is a performance enhancing tool treat it as such don't use it as a performance management tool.

Help persuade NICE to write and publish QOF style business rulesets for all NICE guidance and Quality Standards so that they can be uniformally applied and monitored across the 300,000,000 consultations that occur in primary care each year.

Contact details

Peter Green
Medical Director
NHS Kent and Medway

Primary care
Is the example industry-sponsored in any way?