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Quality and productivity (QP) indicator 6

The practice meets internally to review the data on secondary care outpatient referrals provided by the PCO.

Quality and productivity 6.1 Practice guidance

The PCO must provide practices with data on secondary care referrals which the practice reasonably requires to conduct the review. Practices should discuss with their PCO what data is required for the practice meeting and when.

Clinicians in the practice will meet at least once during the year to carry out the internal review. This meeting should involve the range of clinicians working within the practice.

At the meeting the practice identifies any apparent anomalies in referral patterns and discuss the reasons why this might be the case. Practices should compare the referral patterns with reference to existing care pathways in order to identify areas where improvement might be made to decision making on referrals. The output of this review must be made available to the group of practices taking part in the external peer review.

Quality and productivity 6.2 Reporting and verification

The practice produces a report summarising the discussions that have taken place at the meeting.

This report should be submitted to the PCO no later than 31 March 2013.

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Quality and productivity (QP) indicator 7

The practice participates in an external peer review with a group of practices to compare its secondary care outpatient referral data either with practices in the group of practices or with practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO.

Quality and productivity 7.1 Practice guidance

The practice will identify a group of practices with which it will carry out an external review of their secondary care outpatient referrals. The group must contain a minimum of six practices that share similar referral routes (e.g. refer patients to a similar set of services).

The external review must consist of a comparison of the practice data with comparable data from the practices in the group or from all practices in the PCO area to determine why there are any variances and where it may be appropriate for the practice to amend current arrangements for the management of hospital referrals. The focus of review will be to reflect on referral behaviour and whether clinicians can learn from the data to improve how they refer and if they can reduce unnecessary hospital attendances either by following existing care pathways more closely or through the use of alternative care pathways.

Following the review, the practice should propose areas for commissioning or service design improvement to the PCO.

Quality and productivity 7.2 Reporting and verification

The practice produces a report detailing that an external review has taken place involving the practices in the group. The report must include a summary of the discussions that have taken place during the review meetings, which practices have been involved and what areas have been proposed for commissioning or service design improvement.

The report must be submitted to the PCO no later than 31 March 2013.

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Quality and productivity (QP) indicator 8

The practice engages with the development of and follows 3 agreed care pathways for improving the management of patients in the primary care setting (unless in individual cases they justify clinical reasons for not doing this) to avoid inappropriate referrals and produces a report of the action taken to the PCO no later than 31 March 2013.

Quality and productivity 8.1 Practice guidance

It is expected that PCOs will lead the development of care pathways as defined above, working with practice groups. The PCO may, if the contractor consents, seek the views of the LMC if any for its area on the development of the care pathway.

GPs in the practice must actively respond to the care pathway development process for the purpose of this indicator. This may, for example, involve attending meetings with other health professionals concerned with the care pathway or commenting to the pathway group electronically. The three care pathways cannot be the same as those identified for indicator QP11. Where possible, the focus of the care pathways should be on long term conditions.

Practices must then follow the agreed care pathways in the treatment of their patients, unless in individual cases they can justify clinical reasons for not doing this.

Quality and productivity 8.2 Reporting and verification

The practice produces a report summarising the action taken, information about which care pathways were followed and changes in the patterns of referral that have resulted.

This report should be submitted to the PCO by 31 March 2013.

Achievement will be awarded on the basis that practices have both engaged in the development of care pathways and delivered care along the agreed care pathways.

It is expected that a practice will follow the agreed care pathways for all patients. However, it is recognised that it may not be clinically appropriate for every patient, for example not all patients may be able to tolerate certain drugs. In these circumstances the report should show that the practice has considered following the care pathway in treating these patients and has documented reasons why it is not clinically appropriate in those individual circumstances.

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Quality and productivity (QP) indicator 9

The practice meets internally to review the data on emergency admissions provided by the PCO.

Quality and productivity 9.1 Practice guidance

The PCO must provide practices with data on emergency admissions which the practice reasonably requires to conduct the review. Practices should discuss with their PCO what data is required for the practice meeting and when.

Clinicians in the practice will meet at least once during the year to carry out the internal review. This meeting should involve the range of clinicians working within the practice. Emergency admissions are defined as admissions that are unpredictable and at short notice because of clinical need. (NHS Data Dictionary – Admission method codes 21, 22, 23, 24 and 28. http://www.datadictionary.nhs.uk/data_dictionary/attributes/a/add/admission_method_de.asp?shownav= 1)

Practices should explore the reasons for emergency admissions with reference to available pathways in order to identify areas where improvement might be made.

The output of this review must be made available to the group of practices taking part in the external peer review.

Quality and productivity 9.2 Reporting and verification

The practice produces a report summarising the discussions that have taken place at the meeting.

This report should be submitted to the PCO no later than 31 March 2013.

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Quality and productivity (QP) indicator 10

The practice participates in an external peer review with a group of practices to compare its data on emergency admissions either with practices in the group of practices or practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO.

Quality and productivity 10.1 Practice guidance

The steps outlined in indicator QP7 apply to QP10, with references to “secondary outpatient referrals” replaced with references to “emergency admissions”.

Quality and productivity 10.2 Reporting and verification

The practice produces a report detailing that an external review has taken place involving the practices in the group. The report must include a summary of the discussions that have taken place during the review meetings, which practices have been involved and what areas have been proposed for commissioning or service design improvement.

The report must be submitted to the PCO no later than 31 March 2013.

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Quality and productivity (QP) indicator 11

The practice engages with the development of and follows 3 agreed care pathways (unless in individual cases they justify clinical reasons for not doing this) in the management and treatment of patients in aiming to avoid emergency admissions and produces a report of the action taken to the PCO no later than 31 March 2013.

Quality and productivity 11.1 Practice guidance

The steps outlined in indicator QP8 apply to indicators QP11, with references to “secondary outpatient referrals” replaced with references to “emergency admissions”.

Quality and productivity 11.2 Reporting and verification

The practice produces a report summarising the action taken, information about which care pathways were followed and changes in the rates of emergency admissions that have resulted.

This report should be submitted to the PCO by 31 March 2013.

Achievement will be awarded on the basis that practices have both engaged in the development and delivered care along the agreed pathways.

Achievement will be awarded on the basis that practices have both engaged in the development and delivered care along the agreed pathways. It is expected that a practice will follow the agreed care pathways for all patients. However, it is recognised that it may not be clinically appropriate for every patient, for example not allpatients may be able to tolerate certain drugs. In these circumstances the report should show that the practice has considered following the care pathway in treating these patients and has documented reasons why it is not clinically appropriate in those individual circumstances.

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Quality and productivity (QP) indicator 12

The practice meets internally to review the data on accident and emergency attendances provided by the PCO no later than 31 July 2012. The review will include consideration of whether access to clinicians in the practice is appropriate, in light of the patterns on accident and emergency attendance.

Quality and productivity 12.1 Practice guidance

The PCO must provide practices with data from the final quarter of the 2011/12 financial year (1 January to 31 March 2012) on Accident and Emergency (A&E) attendances which the practice reasonably requires to conduct the review. The data should where possible include patient details, reasons for attendance/diagnosis and the time/date of attendance. Practices should discuss with their PCO what data is required for the practice meeting and by when. Thereafter, PCOs must provide monthly data.

Attendances at A&E are defined as those patients seen in a Type 1 A&E department for both first and follow-up attendances for the same condition (excluding planned follow-ups). The definition in the document A&E Clinical Quality Indicators Data Definitions, published by the Department of Health in England, defines a Type 1 A&E department as “a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients”.

In circumstances where there is no Type 1 A&E department or where the majority of patients do not use a Type 1 A&E department, then practices and PCOs should agree the most frequently used local urgent care service and agree those that will be included (for example Type 2 and/or Type 3 A&E departments). The type of A&E attendance will be limited to both first and followup attendances for the same condition (excluding planned follow-ups).

Further information: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasse t/dh_122892.pdf

Clinicians in the practice will meet at least once (before 31 July 2012) to carry out the internal review. This meeting should involve the range of clinicians working within the practice.

At the meeting the practice explores the reasons for registered patients’ attendance(s) at A&E and any emerging patterns and discusses this with reference to available care pathways and the capability and access within primary care to see and treat patients. In the discussion, focus should be given to (1) older patients with co-morbidities at high risk of admission (patients aged 65 years and over), (2) children with minor illness/injury (patients aged 15 years and under) and (3) patients who frequently re-attend A&E that could be dealt with in primary care. The review should also specifically consider whether same day access to clinicians in the practice is appropriate and whether any comparisons can be drawn between this and the level of A&E attendances. The practice then uses this information to identify where improvements might be made to reduce avoidable A&E attendances.

The output of this review must be made available to the group of practices taking part in the external peer review (see QP13). In developing the final report, practices may find it useful to refer to the Primary Care Foundation Report Urgent Care - A Practical Guide to Reforming Same Day Care in General Practice published in 2009. The report is available at: www.primarycarefoundation.co.uk/images/PrimaryCareFoundation/Downloading_Reports/Reports_and_Articles/Urgent_Care_Centres/Urgent_Care_May_09.pdf

Quality and productivity 12.2 Reporting and verification

The practice produces a report summarising the discussions that have taken place at the meeting. The report should include information on the practices current access arrangements.

This report should be submitted to the PCO no later than 31 July 2012.

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Quality and productivity (QP) indicator 13

The practice participates in an external peer review with a group of practices to compare its data on accident and emergency attendances, either with practices in the group of practices or practices in the PCO area and agrees an improvement plan firstly with the group and then with the PCO no later than 30 September 2012. The review should include, if appropriate, proposals for improvement to access arrangements in the practice in order to reduce avoidable accident and emergency attendances and may also include proposals for commissioning or service design improvements to the PCO.

Quality and productivity 13.1 Practice guidance

The practice will identify a group of practices with which it will carry out an external review of their A&E attendances. The group must contain a minimum of six practices unless the PCO otherwise agrees having due regard to local geography and the historical groupings of practices. Where possible, the practices should share similar care pathways and/or geographical locations. The groups may be the same as those used for other QP indicators.

The external review must consist of a comparison of the practice data with comparable data from the practices in the group or from all practices in the PCO area to determine why there are any variances and where it may be appropriate for the practice to amend current arrangements to help reduce avoidable A&E attendances. The focus of the review will be to reflect on the reasons and/or patterns of A&E attendances, and identify where improvements may be made to improve the quality of care for patients at the interface of primary care and A&E, in order to help reduce avoidable A&E attendances. Again, both in the discussion and final improvement plan, focus should be given to (1) older patients with co-morbidities at high risk of admission, (2) children with minor illness/injury and (3) patients who frequently re-attend A&E, that could be dealt with in primary care.

In circumstances where practices are already managing their patients in a way that means they have very low levels of ‘avoidable A&E attendances’, the plan may focus on how the practice intends to maintain or further reduce the current level of ‘avoidable A&E attendances’.

Practices may also propose, via the peer group, areas for commissioning or service design improvements to the PCO that could help to reduce avoidable A&E attendances.

Following the review, the practice improvement plan is either amended or agreed by the group and a final improvement plan is then submitted to the PCO for agreement by no later than 30 September 2012.

Quality and productivity 13.2 Reporting and verification

The practice produces a report detailing that an external review has taken place involving the practices in the group. The report must include a summary of the discussions that have taken place during the review meetings, which practices have been involved and details of the agreed improvement plan that aims to reduce avoid able A&E attendances.

The report must be submitted to the PCO no later than 30 September 2012.

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Quality and productivity (QP) indicator 14

The practice implements the improvement plan that aims to reduce avoidable accident and emergency attendances and produces a report of the action taken to the PCO no later than 31 March 2013.

Quality and productivity 14.1 Practice guidance

The practice will implement the arrangements and actions set out in their improvement plan and provide evidence to support their implementation to the PCO.

Practices will need to review their monthly data on the percentage of (1) older patients with comorbidities at high risk of admission, (2) children with minor illness/injury and (3) patients who frequently re-attend A&E and where possible, provide information on how improvements in care and access to primary care have been made for these patients.

Quality and productivity 14.2 Reporting and verification

The practice produces a report summarising the details of the improvement plan and the action taken to aim at reducing avoidable A&E attendances.

The report should include information about (1) older patients with co-morbidities at high risk of admission, (2) children with minor illness/injury and (3) patients who frequently re-attend A&E and how any improvements in care and access in primary care have helped to reduce avoidable A&E attendances. If the data quality provided to the practice does not allow this to be done for all patients this should be noted in the report.

This report should be submitted to the PCO no later than 31 March 2013.

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Prepared By Jean Keenan