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Quality and productivity (QP) indicator 001

The contractor reviews data on secondary care outpatient referrals, for the patients on the contractor's registered list, provided by the NHS CB

Quality and productivity 001.1 Rationale

The NHS CB is responsible for providing contractors with data on secondary care referrals, for patients on the contractor's registered list, which the contractor reasonably requires to conduct the review. Contractors should discuss with the NHS CB what data is required for the review meeting and when. The NHS CB will work in partnership with clinical commissioning groups (CCGs) at a local level to agree the most appropriate way of fulfilling this function

Clinicians in the practice will meet at least once during the year to carry out the internal review. It is recommended that the meeting involves the range of clinicians working within the practice.

At the meeting the contractor identifies any apparent anomalies in referral patterns and discusses the reasons why this might be the case. Contractors are advised to compare the referral patterns with reference to existing care pathways in order to identify areas where improvements might be made to the referrals process.

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

Quality and productivity 001.2 Reporting and verification

The contractor may be asked to provide a summary of the discussions that took place at the meeting. This may be in the form of a meeting note.

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Quality and productivity (QP) indicator 002

The contractor participates in an external peer review with other contractors who are members of the same clinical commissioning group to compare its secondary care outpatient referral data with that of the other contractors. The contractor agrees with the group areas for commissioning or service design improvements

Quality and productivity 002.1 Practice guidance

The contractor will identify a group of contractors, who are members of the same CCG, with which it will carry out an external review of their secondary care outpatient referrals. The group should contain a minimum of six practices unless the NHS CB agrees otherwise. The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate arrangements.

The external review should consist of a comparison of the contractor's data with comparable data from the other contractors in the group. This is to determine why there are variances and where it may be appropriate for the contractor to amend current arrangements for the management of hospital referrals. The focus of the review should 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 contractor should agree with the other contractors in the group, areas for commissioning or service design improvements.

Quality and productivity 002.2 Reporting and verification

The contractor may be asked to provide a summary of the review meeting, including when the external review took place, who was involved, the key discussion points (if any) and what areas have been proposed for commissioning or service design improvement. This may be in the form of a meeting note.

For indicators QP002, QP005 and QP008, the contractor will identify a group of contractors, who are members of the same CCG, with which it will carry out the external review. The group should contain a minimum of six practices unless the NHS CB agrees otherwise. The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate arrangements.

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Quality and productivity (QP) indicator 003

The contractor engages with the development of and follows 3 care pathways, agreed with the NHS CB, 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 outpatient referrals

Quality and productivity 003.1 Rationale

The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate arrangements to agree the three care pathways with contractors. It is expected that CCGs will lead the development of care pathways working with contractor groups. The CCG may, if the contractor consents, seek the views of the LMC for its area on the development of the care pathway.

Contractor GPs should actively respond to the care pathway development process for the purpose of this indicator. This may, for example, involve attending meetings with other healthcare professionals concerned with the care pathway or commenting to the pathway group electronically. Where possible, focus of the care pathways is to be on long-term conditions.

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

Quality and productivity 003.2 Reporting and verification

The contractor may be asked about which care pathways were followed and if any changes in the patterns of referral have resulted.

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

It is expected that a contractor 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 contractor may be asked whether consideration was given for following the care pathway in treating these patients and the reasons as to why it was not clinically appropriate in those individual circumstances.

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Quality and productivity (QP) indicator 004

The contractor reviews data on emergency admissions, for patients on the contractor's registered list, provided by the NHS CB

Quality and productivity 004.1 Rationale

The NHS CB is responsible for providing contractors with data on emergency admissions, for patients on the contractor's registered list, which the contractor reasonably requires to conduct the review. Contractors should discuss with the NHS CB what data is required for the review meeting and when. The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate way of fulfilling this function..

Clinicians in the practice will meet at least once during the year to carry out the internal review. It is recommended that this meeting involves 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)

Exploration of the reasons for emergency admissions with reference to available pathways could be useful for the contractor, in helping to identify areas where improvement might be made.

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

Quality and productivity 004.2 Reporting and verification

The contractor may be asked to provide a summary of the discussions that took place at the meeting. This may be in the form of a meeting note.

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Quality and productivity (QP) indicator 005

The contractor participates in an external peer review with other contractors who are members of the same clinical commissioning group to compare its data on emergency admissions with that of the other contractors. The contractor agrees with the group areas for commissioning or service design improvements

Quality and productivity 005.1 Practice guidance

The steps outlined in indicator QP002 apply to QP005, with references to "secondary outpatient referrals" replaced with references to "emergency admissions".

Quality and productivity 005.2 Reporting and verification

The contractor may be asked to provide a summary of the review meeting, including when the external review took place, who was involved, the key discussion points (if any) and what areas have been proposed for commissioning or service design improvement. This may be in the form of a meeting note.

For indicators QP002, QP005 and QP008, the contractor will identify a group of contractors, who are members of the same CCG, with which it will carry out the external review. The group should contain a minimum of six practices unless the NHS CB agrees otherwise. The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate arrangements.

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Quality and productivity (QP) indicator 006

The contractor engages with the development of and follows 3 care pathways, agreed with the NHS CB (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

Quality and productivity 006.1 Contractor guidance

The steps outlined in indicator QP003 apply to QP006, with references to "secondary outpatient referrals" replaced with references to "emergency admissions".

Quality and productivity 006.2 Reporting and verification

The contractor may be asked about which care pathways were followed and if any changes in the rates of emergency admissions have resulted.

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

It is expected that a contractor 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 will be able to tolerate certain drugs. In these circumstances the contractor may be asked whether consideration was given for following the care pathway in treating these patients and the reasons as to why it is was not clinically appropriate in those individual circumstances.

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Quality and productivity (QP) indicator 007

The contractor reviews data on accident and emergency attendances, for the patients on the contractor's registered list, provided by the NHS CB. The review will include consideration of whether access to clinicians in the contractors premises is appropriate, in light of the patterns on accident and emergency attendance

Quality and productivity 007.1 Rationale

The NHS CB is responsible for providing contractors with data on A&E attendances, for patients on the contractor's registered list, which the contractor reasonably requires to conduct the review. It is advised that the initial data provided should be from the final quarter of 2012/13 financial year (1 January to 31 March 2013) and thereafter updated data should be provided monthly. The data should where possible include patient details, reasons for attendance/diagnosis and the time/date of attendance. Contractors should discuss with the NHS CB what data is required for the review meeting and by when. The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate way of fulfilling this function.
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 DH in England defines Type 1 A&E department as "a consultant led 24-hour service with full resuscitation facilities and designated accommodation for the reception of A&E 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, contractors should identify the most frequently used local urgent care service and agree with the NHS CB, working in partnership with CCGs, 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 follow-up 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 to carry out the internal review. It is recommended that this meeting involves the range of clinicians working within the practice.

At the meeting the contractor 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. It is advised that 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.

The review should also specifically consider whether same day access to clinicians in the contractor's premises is appropriate and whether any comparisons can be drawn between this and the level of A&E attendances. The contractor then uses this information to identify where improvements might be made to reduce avoidable A&E attendances.

The output of this review should be made available to the other contractors in the group taking part in the external peer review (see QP007).

Quality and productivity 007.2 Reporting and verification

The contractor may be asked to provide a summary of the review meeting, including when the review took place and the key discussions points (if any). This may be in theform of a meeting note. The contractor may also be asked what the current access arrangements are.

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Quality and productivity (QP) indicator 008

The contractor participates in an external peer review with other contractors who are members of the same clinical commissioning group to compare its data on accident and emergency attendances with that of the other contractors. The contractor agrees an improvement plan with the group. The review should include, if appropriate, proposals for improvement to access arrangements to the contractors premises in order to reduce avoidable accident and emergency attendances and may also include proposals for commissioning or service design improvements

Quality and productivity 008.1 Rationale

The contractor will identify a group of contractors, who are members of the same CCG, with which it will carry out an external review of their A&E attendances. The group should contain a minimum of six practices unless the NHS CB agrees otherwise. The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate arrangements. The groups may be the same as those used for other QP indicators.

The external review should consist of a comparison of the contractor's data with comparable data from the other contractors in the group. This is to determine the reasons why there are any variances and where it may be appropriate for the contractor 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, it is advised that 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 contractors 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 contractor intends to maintain or further reduce the current level of 'avoidable A&E attendances'.

Contractors may also propose areas for commissioning or service design improvements with the other contractors in the group that could help to reduce avoidable A&E admissions.

Following the review, an improvement plan for each contractor is agreed by the contractors in the group and the relevant improvement plan is held by the contractor. A copy of the improvement plan is to be made available for review by the NHS CB upon request.

Quality and productivity 008.2 Reporting and verification

The contractor may be asked to provide a summary of the review meeting, including when the external review took place, who was involved, the key discussion points (if any) and details of the agreed improvement plan that aims to reduce avoidable A&E attendances. This may be in the form of a meeting note that includes the agreed improvement plan.

For indicators QP002, QP005 and QP008, the contractor will identify a group of contractors, who are members of the same CCG, with which it will carry out the external review. The group should contain a minimum of six practices unless the NHS CB agrees otherwise. The NHS CB will work in partnership with CCGs at a local level to agree the most appropriate arrangements.

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Quality and productivity (QP) indicator 009

The contractor implements the improvement plan that aims to reduce avoidable accident and emergency attendances

Quality and productivity 009.1 Rationale

The contractor will implement the arrangements and actions set out in their improvement plan and retain evidence to support the implementation which is to be made available to the NHS CB upon request.

Contractors will need to review their monthly data on the percentage of patients who frequently re-attend A&E and consider how improvements in care and access to primary care can be made for these patients.

Quality and productivity 009.2 Reporting and verification

The contractor may be asked to provide the improvement plan and a summary of action taken aimed at reducing avoidable A&E attendances.

Verification - information may be requested about 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 contractor does not allow this to be done for all patients then it is to be noted.

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Prepared By Jean Keenan