The new quality improvement (QI) indicators are a major addition to QOF in 2019/20, with points transferred from retired clinical indicators.
Unlike the rest of QOF which is set for five years, these areas will only run for a year each, with a new focus each year.
For 2019/20, there are two new QI indicators in the area of prescribing safety. Another two new indicators introduced this year focus on end of life care and are outlined separately.
Prescribing safety is to be monitored in three areas:
The last two are likely to apply to quite small numbers of patients. If there are no patients at all being prescribed lithium it is permissible to substitute another drug such as amiodarone, phenobarbital or methotrexate.
The valproate prescribing policy should be reviewed, even if no women are being prescribed valproate.
Identify areas for improvement
The first thing to do is a baseline audit. Practice computer systems already have searches for valproate prescribing in women of child-bearing potential and these should be used to audit current care.
The searches to identify patients not meeting the standards for NSAID and lithium prescribing are likely to be very similar to most practices and can be shared. These should be sufficient in the vast majority of cases.
Valproate searches have been available for the last year. In other cases the searches should be relatively easy to construct if none are available.
Set quality improvement activities and goals
You will need to create a plan and targets based on the result of the audit. Practices should choose targets based on severity of risk, urgency of assessment and skills of practice staff. In the contract jargon, the objectives should be Specific, Measurable, Achievable, Relevant and Time-bound (SMART).
Practices can produce their own targets but, given the areas specified, there is not a lot of room for manoeuvre. The contract document gives a list of example targets and several other pages of information.1 It is likely that most practices will be able to use the examples with minimal modification.
For lithium and valproate at least, the number of patients involved are likely to be small. You may spend more time writing this up than reviewing patients.
Example objectives include ensuring that no patients are prescribed NSAIDs if they have a recorded contraindication. Another suggests that all patients receiving lithium prescriptions should have had a lithium level checked every six months, effectively replacing the withdrawn QOF indicator.
Another example is the application of guidance on the prescribing of valproate. This will include advice and documentation including patient information. Resources for female patients of reproductive age on valproate are available from the Department of Health and Social Care.
NHS England has also published a series of case studies for the new QI prescribing safety indicators.2
Implement planned activities
It makes sense to do as much of this as possible at the start of the year to allow time to undertake any reviews and have the appropriate meetings (see second indicator below). Unless you have some excellent reason to do something individual I would suggest sticking with the examples provided. This indicator is a test of implementation, not imagination.
After implementation changes and the completion of the audit cycle there is a standard form to report results. There is a ‘homework’ feeling to this as you are expected to fill the page at 11-point Ariel text. In practice this is around 400-500 words.
These meetings would normally be towards the start and end of the year. These are expected to be face to face, although other options may be available after consultation with the CCG.
The first meeting will be about initial audits and plans for change. There is no obligation for all practices at the meeting to use the same objectives but it is likely to reduce the work involved if practices can share the effort and resources.
The second meeting will focus on the results of changes to patients and the practice and what further activities would be useful or appropriate. It also suggests celebrating success.
It is anticipated that most practices will hold the meeting with their networks. Practices which are not part of a network will make arrangements with their CCG. These two meetings could be combined with the equivalents required for the end of life QI indicators to make organisation a little simpler.
As the payment for this indicator is based on the number of patients, but the number of meetings is constant, these are much more lucrative to larger practices. However with ten points overall it is still likely to be worthwhile to all but the very smallest practices.
NHS England: Examples of SMART objectives
Objective 1: Baseline practice prescribing analysis identifies patients on regular NSAID prescriptions with a recorded contraindication.
SMART outcome: Repeat analysis after three months (and repeated at three-monthly intervalsthereafter) shows NO PATIENTS with a recorded contraindication have been prescribed NSAIDS.
Objective 2: Baseline practice prescribing analysis shows only 5% of patients obtaining a regular (repeat) NSAID have had a clinical safety risk assessment clearly documented within the last 12 months.
SMART outcome: Increase from 5% to X% over the next 6 months (practice to decide) and X-Y% over the 6-12 months (practice to decide) of people prescribed NSAIDs regularly have a documented clinical safety risk assessment (as part of their medication review) as per NICE advice within the preceding 12months.
Objective 3: Baseline practice prescribing analysis shows 50% of patients prescribed lithium for more than one year and suitable (as per NICE guidance) for six monthly checks had had a recorded serum lithium level checked within the last six months.
SMART outcome: At a repeat analysis six months after the baseline analysis there is an increase from 50% to X% (practice to decide) of patients prescribed lithium for greater than a year who are suitable for six monthly checks and who have a recorded serum lithium level within the last six months.
Objective 4: Baseline practice prescribing analysis shows no girls or women of childbearing potential are currently prescribed valproate without a highly effective pregnancy prevention plan in place as per MHRA guidelines. However, no practice system is in place to routinely identify new potential at risk patients.
SMART outcome: Within one month, the practice can demonstrate an appropriate repeated monthly search of the clinical system to identify that all girls or women of childbearing potential who have been recommended to start valproate medication have had a clinical review to ensure compliance with the pregnancy prevention programme, as recommended by the MHRA.
Dr Gavin Jamie is a GP in Swindon and runs the QOF database website
Or, please register for a free trial to access all of the guides and unlock all features.
© Cogora 2024
