Maria Kordowicz

Identifying poorly performing general practices in England: a longitudinal study using data from the quality and outcomes framework

Objective To determine the characteristics of general practices which perform poorly in terms of Quality and Outcome (QOF) performance indicators in Englands NHS. Method Retrospective, four year longitudinal study, 2005 to 2008. Data were obtained from 8515 practices (99% of practices in England) in year 1, 8264 (98%) in year 2, 8192 (98%) in year 3 and 8256 (99%) in year 4. Outcome measures: QOF performance scores; social deprivation (IMD-2007) and ethnicity from the 2001 national census; general practice characteristics. Results We identified a cohort of 212 (2.7%) practices which remained in the lowest decile for total QOF scores in the four years following the introduction of the QOF. A total of 705,386 patients were registered at these practices in year 4. These practices were more likely to be singlehanded (odds ratio [OR], 13.8), non-training practices (OR, 3.9) and located in deprived areas (OR, 2.6; most vs least deprived quintiles). General practitioners (GPs) in these practices were more often aged ≥65 years or more (OR, 7.3; mean GP age ≥65 years vs <45 years), male (OR 2.0), UK qualified (OR 2.0) with small list sizes (OR 3.2; list size <1000 vs 1500-2000 patients). We identified individual QOF indicators which were poorly achieved. The reported prevalence of most chronic diseases was lower in the poorly performing cohort. Conclusions A small minority of practices have remained poor performers in terms of measurable performance indicators over a four-year period. The strongest predictors of poor QOF performance were singlehanded and small practices, and practices staffed by elderly GPs.

How does an accreditation programme drive improvement on acute inpatient mental health wards? An exploration of members' views

Background: Concerns have been raised about inpatient mental health care. An accreditation model can improve compliance with standards associated with improved quality of health care. Aims: To explore the effects of a standards-based, peer review, accreditation model on standards of care in acute inpatient wards and explore how staff achieved change. Method: Quality of care was assessed by independent peer review against evidence-based standards in an accreditation process. Staff from the 11 wards receiving subsequent accreditation were interviewed to find out what processes had enabled accreditation. Results: Sixteen wards enrolled: four achieved immediate and 11 subsequent accreditation. The most common reasons for initial failure of accreditation were lack of psychological therapies or 1:1 time for patients, and presence of ligature points. Ward staff perceived the accreditation process improved communication, gave power to negotiate for resources, clear guidance how to practice, rewarded good practice and led to additional unrelated improvements in care. Conclusions: Acute wards need to attend to basic safety and provide talking treatments (both formal psychotherapy and basic time spent with patients). An accreditation, peer-reviewed, standards-based process can enable staff to feel confident about improvements in the quality of care.

Quality and Outcomes Framework: time to take stock

We are now living in the seventh annual cycle of the Quality and Outcomes Framework (QOF). So ingrained has QOF become for everyone working in UK primary care, that it is hard to imagine life before QOF. It is hard too, to recall the revolutionary changes that accompanied its arrival. Prior to QOF, there were just two targets for general practice in the UK: childhood immunisations and cervical smears. Suddenly, on 1 April 2004, along came targets for 147 indicators. Initially, 76 of these were clinical targets covering 10 long-term conditions. These were revised in 2006 to 80 targets covering 19 long-term conditions. Implementation occurred within a cultural context which it is important to review when considering future directions for QOF. The story of the precursors and prerequisites of QOF has already been well told.1 In the time leading up to the arrival of QOF, there was public concern about the poor quality of public services, a growing culture of public sector accountability, acceptance that the NHS was underfunded when compared with other European countries, increasing dissemination of information from the evidence-based medicine movement, and a backdrop of economic growth accompanied by the political will to invest in public services. These factors combined with something of a crisis in primary care: GP recruitment was at an all-time low and a substantial boost to GP income was offered, with QOF as the vehicle. QOF was implemented as a pay-for-performance (P4P) system, structured so that it contained evidence-based indicators and was weighted according to the anticipated workload demands that each indicator would place on an average general practice. The achievements of QOF have been considerable. It is undoubtedly the most comprehensive, far-reaching P4P system in the world. It has demonstrated high median levels (far higher than originally predicted) of primary care …

Capturing general practice quality: a new paradigm?

While overwhelmingly quality is presented by policymakers as measurable and as meeting predefined top-down targets, we argue that quality in general practice is multiform and multifaceted. Quality is a notion that is hugely difficult to pin down in all its richness and complexity and countless attempts have been made at defining quality in health care. Definitions range from the more concrete (quality as access and effectiveness for instance,1) to the abstract (quality as purely a social construct rather than an objective entity2). Therefore, there exists a clear challenge of unifying the practical realities of general practice with subjective norms into one concept. The coalition government’s agenda preaches values of openness and transparency through improved information capture to raise the quality of patient care.3 The type of information favoured for this purpose tends to take a numerical form, usually lending itself more quickly and readily to comparisons across services and strategic decision making than its ‘softer’ qualitative counterparts. The dominant method of data facilitation in general practice is of course the Quality and Outcomes Framework (QOF), which has been with us since the introduction of the new general medical services (nGMS) contract in 2004. There is no doubt that measurement plays a key part in enabling focused quality improvement initiatives, for instance by identifying need in specific patient populations, and on a wider-level is likely to be a valuable tool in supporting commissioning decisions. QOF monitoring has also resulted in the creation of the largest general practice database in the world, prompting research around processes and outputs and their relationship to outcomes in general practice. However, increasingly, monitoring is viewed as instrumental to quantifying quality. In the face of austerity, top down monitoring feeds into …

A Cross-sectional study to explore the challenges faced by Myanmar women in accessing antenatal care services

Background : Myanmar has one of the highest maternal mortality rates in the Southeast Asian region, with most maternal deaths occuring at the time of delivery. The aim of this research was to identify the relationship between socio-demographic characteristics of Myanmar women and utilisation of antenatal care services. Methods : This is a descriptive cross-sectional study utilising the Myanmar Demographic and Health Survey Data 2015-16. A total of 13,454 women agedbetween 15-49 years were surveyed. This study sampled married women only (n=7870). Results : The mean age of the respondents was 35 years and the majority of respondents (50.7%) belonged to the 35-49 age group. Approximately 46.3% of respondents reported more than four antenatal care service (ANC) visits and almost 54% respondents attended ANC during their second and third trimesters. This study found that women with no education, poorer socioeconomic status, less access to mass media, living in rural areas and with more children were not utilising ANC services adequately. Conclusion : Strategies should be introduced to encourage pregnant women to attend a minimum of four antenatal check-ups and there should be adequate monitoring in place of the timing of ANC visits during pregnancy.

Viewpoint: Professional powerlessness: reflections from a WhatsApp group

My schoolfriend, a junior doctor, added me to a WhatsApp group chat entitled ‘Shenanigans’. Initially, I thought this would be a forum to plan wild nights out as we did before adult life took over and to share hilarious anecdotes. Soon, the irony of the group name dawned on me as I realised why we were hand-picked. All of us, close since the age of 11, are now working in health — as medical consultants, GPs, lawyers, policymakers, civil servants, managers, advisors, and academics — all united by our firmly held …

Research governance: assailing a paper mountain

Here is a personal view of the rigmarole I have been experiencing as a PhD student applying for local Research and Development (R&D) approval to conduct my relatively low-risk study. The very mention of ‘ethics’ and ‘R&D’ elicits sighs all round from the PhD office and this is not without good reason. I, for one, have found the application system complex, inconsistent and at times, rather discouraging. Since 2008, an online Integrated Research Application System (IRAS) has been in operation for the purpose of seeking ethical approval nationally and facilitating local research governance approval. The creation of IRAS followed a Department of Health advisory group report calling for a streamlined ethics application system.1 My first challenge on embarking on this supposedly simpler process was navigating my way around the National Research Ethics Service (NRES) website and its obvious penchant for acronyms. Once I knew my CAS from my SSA, I faced the 70-question ethics form. The nature of …