This incentivised quality improvement programme aimed to elevate population-based primary care provision to exemplary status. It provides direction to general practices through the use of specific aspirational targets, that complement and enhance national schemes, and tailored practice development plans. In addition to financial support, face-to-face advice, education and service development is utilised to improve quality of care across all participating practices.
The programme is relevant to implementation of the following NICE guidelines: NG136, QS6 and NG115.
This example was originally submitted to demonstrate implementation of NICE guideline CG101 and CG127. The guidelines have now been updated and replaced by NG115 and NG136 respectively. The example has been amended to reflect this and remains consistent with the updated guidelines. NG115 and NG136 should be referred to if seeking to replicate any aspects of this example.
Aims and objectives
The NHS Stoke on Trent Quality Improvement Framework (QIF) programme was initially designed to enhance quality of care at a local population level over a three year timeframe from 2009. The duration of the programme has since been extended for a further four years as a result of the value that has been demonstrated by this approach.
The QIF programme was developed to improve the local population's health and life expectancy through the increased identification of patients with long-term conditions who were previously undiagnosed, to increase the ratio of healthcare professionals to patients and to minimise health inequality between the Stoke-on-Trent population and others in the UK and across the local population, for example by reducing exceptions of patients from high quality care. Pragmatic and achievable aspirational quality indicators were established to promote a move towards exemplary practice among local practices. These included organisational and clinical targets directed at quality 'hot spots' in patient pathways.
As the aspirational standards were set to complement the QOF standards and needed to be reactive to local health needs, they have not been static. Therefore, each year the QIF standards have been revised, through 'QIF Refresh', to further refine and enhance quality attainment, and to prevent duplicate payments to practices for achievement of certain targets.
Reasons for implementing your project
Quality improvement within the healthcare system has been a clinical and political hot topic over recent years - in particular in relation to the capability and capacity of delivery of general medical practice care. This is evidenced by the publication and annual revisions of the NHS Outcomes Framework. Primary care is recognised as a key cog in the provision of quality health care and improving quality cannot occur without reducing unwarranted care variation and inequality within a local population and between the local population and nation. Therefore nationally it is recognised that both individual General Practitioners and their associated practices must find ways to drive positive change in quality and equal healthcare provision.
A review of the primary care strategy for NHS Stoke on Trent in 2007-8 recognised the low socioeconomic status and high levels of poor health. The model of general practice in Stoke-on-Trent was incongruous with the national picture. GP list sizes were 20% above the national average for whole time equivalent GP to patient ratio and amongst the highest in the country. About a third of practices were single handed, which was significantly above the national average, and more than 33% of GPs of an age where they might be expected to retire over the next five years. Therefore, the need to improve primary care quality was pressing. Formally pushing quality in primary care is not new. Private and publically funded 'pay-for-performance' policies have been increasingly used for over a decade; most notable was the introduction of the Quality and Outcomes Framework (QOF) in 2004. Although the use of incentivised targets is contentious, some gains have been demonstrated; therefore this approach was adopted and enhanced for the delivery of the local Quality Improvement Framework (QIF).
Expected core and exemplary standards that would meet the aims and objectives of the framework were developed through consideration of the baseline level of healthcare provision and attainments of current targets, deficits inherent in the QOF targets (especially those where QOF standards were 'easier' than NICE standards), demonstrable local health need (e.g. poor lifestyle habits, low standard mortality rates, high levels of cardiovascular risk) and to align targets with current evidence based recommendations, such as those provided by NICE.
How did you implement the project
A Primary Care Development Unit was created to underpin the QIF programme. The unit set individual practice targets, recommended evidence based practice protocols for clinical management (e.g. using NICE guidance), and set attainment targets, against which practices could benchmark themselves. Examples of specific NICE guidance used within current QIF standards are:
-Hypertension NG136 - practices required to have at ≥50% of their patients (aged < 80 years) on hypertension disease register to have at least two blood pressure readings (measured in the previous 15 months; at least 4 months apart) ≤140/90 mmHg
-Diabetes QS6 - QIF requires practices to have ≥60% of patients with diabetes to have a HbA1c measurement < 59 mmol/mol in previous 15 months; including those from minority ethnic groups
-Chronic obstructive pulmonary disease NG115 - QIF requires at least 70% of people with COPD to have a self management plan updated annually (Recommendation 1.2.124). Practices were required to meet a set of pre-qualifying criteria to join QIF. Those failing to meet the criteria were supported to improve and join QIF later in the year.
Practices are rewarded financially according to attainment of the prescribed targets and receive education and tailored, face-to-face support in weaker areas to promote long-term progression towards aspirational targets. The main barriers to implementing QIF were primarily due to it representing an additional, competing priority for practices.
Positive engagement was required to overcome specific barriers:
- Aspirational targets were too high and unattainable short-term
- steps towards targets were incentivised
- Aspirational targets required more staff
- An upfront payment of one third of the total available was provided to fund changes to staffing -
- Uncertainty of how to make it happen along patient pathways
- Evidence based best practice resources were developed, often largely based on NICE. Annually, the cost for QIF is £1.5m which also includes a learning and development fund to extensively support the programme. The staff supporting the scheme include a GP Clinical Lead (0.2 WTE), Practice Development and Performance Manager (1 WTE band 7) and Practice Nurse Lead (0.6 WTE band 7).
The programme has undergone annual evaluation. Most significantly, local population health reports from 2011/12 (http://www.wmpho.org.uk/publications/healthimprovement.aspx) have demonstrated a notable improvement in the population health status.
Comparison of the 2008/9 Health improvement monitoring report with that from 2011/12 shows that cholesterol management (<5mmol/l) for CHD patients has seen the former PCT go from being 8/17 highest PCTs in 2008/9 to 1/17 highest PCTs in 2011/12. Another example is blood pressure management (<140/85 mmHg) for CKD patients which has seen the former PCT being one of the lowest of the 17 PCTs achieving this target in 2008/9 to one of the highest former PCTs in 2011/12 (see supplementary evidence).
Provision of robust data about cost-savings has been hampered by variations in data collection methods and the long-term health benefits that reduction of cardiovascular risk factors has. However, the population health status, achievement of targets, patient satisfaction and use of unscheduled and outpatient care continues to be monitored annually and significant reductions in cardiovascular related morbidity and mortality is expected given the level improvement in the population's risk factors.
Pragmatic estimates tell us that with this extent of improved blood pressure control:
- If we prevented 10 less strokes in patients in a year (without taking into account social care costs / benefits / re-ablement), there would be an approximate saving of £45,000 (per year)
- If 3 less people with stage 4 CKD deteriorate to CKD stage 5 requiring dialysis in a year, there would be an approximate saving of £90,000 (per year).
Key learning points
A key factor in the success of this programme is perceived to be the dynamic nature of the targets used. Targets have been dynamic in a number of ways, the threshold required for payment has changed, the clinical target has been made tighter and in some cases the actual target has completely changed. This has reduced the chance of practices reaching an achievement ceiling, as has been previously identified in QOF, and constantly driving improved quality across an increasingly broad proportion of the local population.
Face-to-face intervention and support has been essential in detecting issues within general practices that may otherwise have gone unnoticed, for example, poor quality premises and poor communication skills.
A drive to improve quality even in the face of difficult decisions is necessary. The strict requirements of QIF highlighted the inadequate services provided by one general practice which, in part, led to it being closed down. Although traumatic for those involved, sometimes such drastic action is required to make a positive population health change.
Another key to success is the involvement of relevant stakeholders in the refreshment of the clinical targets. The QIF has seen extensive consultation with primary care, public health, public representatives, clinical leads and the LMC. This has led to the sustainment of the programme through minor revisions with the evolution of standards as opposed to standards that may result in major disruption in general practice.