QOF

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Cervical screening (CS)

CS indicator 1

The percentage of patients aged from 25 to 64 (from 21 to 60 in Scotland, 20 to 64 in Wales and from 20 to 65 in Northern Ireland) whose notes record that a cervical smear has been performed in the last 5 years.

CS 1.1 Practice guidance

This indicator reflects the previous target payment system for cervical screening and is designed to encourage and incentivise practices to continue to achieve high levels of uptake in cervical screening.

The practice should provide evidence of the number of eligible women aged from 25 to 64 (from 21 to 60 in Scotland, from 20 to 64 in Wales and from 20 to 65 in Northern Ireland) who have had a cervical smear performed in the last 60 months.

This indicator differs from all the other additional service indicators in that a sliding scale will apply between 40 and 80%, in a similar fashion to the clinical indicators.

Exception reporting (as detailed in the clinical section) will apply and specifically includes women who have had a hysterectomy involving the complete removal of the cervix.

Exception reporting From April 2011, the exception reporting rules regarding ‘did not attend’ (DNA) letters for the additional services cervical screening indicators in the QOF have changed. The first two letters from the central cancer screening services inviting a patient to attend for a screening will now count towards the three letters required to code a patient as DNA.

Practices will be responsible for sending out the third letter before a DNA code may be used.

This revised exception reporting criteria is not applicable to practices that have opted to run their own call/recall system. These practices will still be required to issue the all three reminder letters directly in order to meet the DNA criteria. Copies of the letters sent by the practice may be required for assessment purposes.

England. NHS Cancer Screening Programme.
http://www.cancerscreening.nhs.uk/cervical/index.html

Scotland. Scottish Cervical Call/Recall system (SCCRS). (available (through NHS net only).
www.sccrs.scot.nhs.uk

Wales. Cervical Screening Wales.
http://www.screeningservices.org.uk/csw/pub/index.asp

Northern Ireland. The Public Health Agency (PHA) has the lead role in screening in NI. Screening services are jointly commissioned with the Health and Social Care Board (HSCB). The general practice role in screening is through the HSCB.

CS 1.2 Written evidence

There should be a computer print-out showing the number of eligible women on the practice list, the number exception reported and the number who have had a cervical smear performed in the last five years (Grade A). In many areas the PCO may provide these data although, other than patients with hysterectomy, they will be unaware of exceptions, for example patients who have been invited on three occasions but failed to attend or those who have opted out of the screening programme. Practices should remove patients from the denominator in the same way as with the clinical indicators.

CS 1.3 Assessment visit

The print-out should be inspected.

CS 1.4 Assessors’ guidance

The assessors should enquire on how patients who are exception-reported are identified and recorded.

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CS indicator 5

The practice has a system for informing all women of the results of cervical smears

CS 5.1 Practice guidance

It is generally accepted as good practice for all women who have had a cervical smear performed to be actively informed of the result. Responsibility for the system may be outside the practice.

CS 5.2 Written evidence

There should be a description of system and example of letters sent to patients. (Grade C)

CS 5.3 Assessment visit

The team should be questioned on how women are informed of the way they will obtain the result of their smear.

CS 5.4 Assessors’ guidance

A letter sent to the patient containing and explaining the result is ideal.

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CS indicator 6

The practice has a policy for auditing its cervical screening service, and performs an audit of inadequate cervical smears in relation to individual smear-takers at least every two years

CS 6.1 Practice guidance

In this audit the criteria, the results, analysis of results, corrective action, the results of the re-audit and a discussion of them needs to be presented. The standard or level of performance against which the criterion is judged would usually involve looking for smear-takers who are obvious outliers in relation to the reading laboratory’s average for inadequate smears.

CS 6.2 Written evidence

An audit of inadequate smears should be recorded. (Grade A)

CS 6.3 Assessment visit

A discussion with smear-takers should take place, dealing with the audit and any educational needs which arose and how these were met.

CS 6.4 Assessors’ guidance

All the elements for an audit stated in the practice guidance need to be present.

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CS indicator 7

The practice has a protocol that is in line with national guidance and practice for the management of cervical screening, which includes staff training, management of patient call/recall, exception reporting and the regular monitoring of inadequate smear rates

CS 7.1 Practice guidance

If a robust system for the management of cervical screening is not in place then this is an area of great risk for general practice. The policy may have been drawn up outwith the practice and should be in line with national guidance.

See guidance on DNA letters in section CS1.1 practice guidance.

CS 7.2 Written evidence

There should be a written policy covering the issues outlined above. (Grade A)

CS 7.3 Assessment visit

The policy should be discussed with relevant staff and the practice should demonstrate how the systems operate.

CS 7.4 Assessors guidance

It may be necessary to ask the practice to demonstrate how its policy operates.

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Child health surveillance (CHS)

CHS indicator 1

Child development checks are offered at intervals that are consistent with national guidelines and policy

CHS 1.1 Practice guidance

The child health surveillance programme should be based on national guidelines. It is important that the practice has a system to ensure follow-up of any identified problem and that referrals are made as appropriate.

See: Hall,D. and EllimanD.(2003) eds Health for all children (fourth ed) Oxford University Press Oxford

Guidance on Implementation in Scotland. Health for All Children 4 (Hall 4):
www.scotland.gov.uk/Publications/2005/04/15161325/13269

CHS 1.2 Written evidence

There should be a description of the child health surveillance programme and how problems are followed up. (Grade C)

CHS 1.3 Assessment visit

The practice team is asked for details of child health surveillance in the practice and how problems are followed up.

CHS 1.4 Assessors’ guidance

The practice should be aware of which guidelines it has adopted. The assessors should be content that there is a process to ensure problems are followed up.

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Maternity services

MAT Indicator 1

Antenatal care and screening are offered according to current local guidelines

MAT 1.1 Practice guidance

Most local areas have produced guidelines, which should be adopted within the practice.

MAT 1.2 Written evidence

There should be written guidelines on antenatal care and screening. (Grade A)

MAT 1.3 Assessment visit

The assessment should involve a description of antenatal care, using the illustration of one case.

MAT 1.4 Assessors’ guidance

The case should show that the guidance is known and is being used.

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Contraception (SH)

Around 80 per cent of (prescribed) contraception in the UK is provided in general practice.

The vast majority of practices are providing the additional service for contraception and many are also providing enhanced services including long acting reversible contraception (LARC) methods. All practices providing any level of contraception need to be able to advise women about all methods to ensure they can make an informed choice. Clinical staff in practices which are not providing all methods also need enough knowledge of these to refer appropriately those women who have chosen a method which they do not supply. Practices also should be aware of local services and local referral pathways.

Sexual Health Strategy for Scotland. Respect & Responsibility.
http://www.scotland.gov.uk/Resource/Doc/35596/0012575.pdf

NHS Quality Improvement Scotland Sexual Health Services (2008). Standards.
http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=ebc412bc-4cce-46ed- 8441-2da10f731f19&version=-1

This indicator set seeks to increase the awareness of women seeking contraceptive advice in general practices of LARC methods and thus to increase the percentage of women using these methods.

Contraception (SH) indicator 1

The practice can produce a register of women who have been prescribed any method of contraception at least once in the last year, or other appropriate interval e.g. last 5 years for an IUS.

SH 1.1 Rationale

General practices provide 80 per cent of prescribed contraception in the UK. This register is applicable to all methods of contraception that have been prescribed by the practice:

Any woman who has been prescribed any method at least once in the last year (or the appropriate prescribing interval for method of choice) should be included on the register.

This indicator is prospective from 1 April 2009.

SH 1.2 Reporting and verification

The practice reports the number of women prescribed any method of contraception in the preceding 1 April to 31 March (or longer if appropriate for the method of choice).

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Contraception (SH) indicator 2

The percentage of women prescribed an oral or patch contraceptive method who have also received information from the practice about long acting reversible methods of contraception in the preceding 15 months.

SH 2.1 Rationale

A womanˇ¦s contraceptive needs can change over her reproductive lifespan. Women requiring contraception should be given detailed information about and offered a choice of all methods, including long-acting reversible contraception (LARC). This indicator seeks to encourage practices to review these needs on a regular basis and ensure that women are informed of advances in contraceptive choices.

All currently available LARC methods are more cost-effective than the combined oral contraceptive even at one year of use. LARC methods include IUDs, the intrauterine system (IUS), injectable contraceptives and implants. This is largely because their effectiveness is independent of patient compliance. Of the LARC methods, injectable contraceptives are the least cost-effective. Increasing the uptake of LARC methods will reduce the number of unintended pregnancies. However, currently in the UK, about eight per cent of contraceptive users use LARC. Whilst international comparison is difficult, this percentage is very low.

NICE clinical guideline 30 (2005). Guidance on LARCs http://www.nice.org.uk/Guidance/CG30

Information from the practice should be written and verbal. Leaflets can be obtained from a number of sources including the Family Planning Association, a UK-wide sexual health charity, which produces an excellent range of contraception leaflets including 'Your Guide to Contraception', which, among other things, indicates LARC and non-LARC methods clearly through the use of shading.

See http://www.fpa.org.uk/Information/Readourinformationbooklets/guide

Faculty of Sexual & Reproductive Healthcare guidelines on contraceptive methods are available at www.ffprhc.org.uk.

SH 2.2 Reporting and verification

The practice reports the percentage of those women prescribed oral or transdermal contraception who have a record of having been given advice on LARC methods in the preceding 15 months.

Verification - practices should be prepared to demonstrate how patients are given such advice, examples of leaflets and any specific practice protocols.

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Contraception (SH) indicator 3

The percentage of women prescribed emergency hormonal contraception at least once in the year by the practice, who have received information from the practice about long acting reversible methods of contraception at the time of, or within 1 month of, the prescription.

SH 3.1 Rationale

Women requiring emergency hormonal contraception should be given detailed information about and offered a choice of all methods, including LARC. It is often possible (and in many cases ideal practice) to commence an ongoing method of contraception at the same time as emergency hormonal contraception is given.

Some women seeking emergency contraception may be best served by being offered an emergency IUD. Emergency IUDs offer a slightly longer window period for action after unprotected intercourse than hormonal EC; they have a higher efficacy in prevention of pregnancy - and they provide excellent ongoing contraception if required.

Information from the practice should be written and verbal. Leaflets can be obtained from a number of sources however the Family Planning Association, a UK-wide sexual health charity, has an excellent range of contraception leaflets including 'Your Guide to Contraception', which, amongst other things, indicates LARC and non-LARC methods clearly through the use of shading.

SH 3.2 Reporting and verification

The practice reports the percentage of those women prescribed emergency hormonal contraception who are recorded as having received advice on LARC methods at the time of, or within one month of the most recent script for emergency hormonal contraception.

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Prepared By Jean Keenan