Prescribing & Medicines Management
page PM4
December 2005

Features

Contributing to a QOF assessment

The Quality and Outcomes framework (QOF) is the core funding stream of the new general medical services contract. GP practices achieving QOF standards and targets are rewarded financially. The medicines management team (MMT) was asked to collect evidence for a number of medicines management-related QOF indicators for each of the 62 GP practices in Central Liverpool Primary Care Trust and to submit reports to the QOF assessor teams before practices were assessed. Evidence on the following indicators was collected:

· For each repeat medicine, the patient’s records state why the medicine was prescribed, ie, an indication (“record indicator 9”)

· For all patients being prescribed four or more repeat medicines, a medication review undertaken in the preceding 15 months is recorded in the patients’ notes (“medicines indicator 5”)

· For all patients being prescribed any repeat medicine, a medication review undertaken in the preceding 15 months is recorded in the patients’ notes (“medicines indicator 9”)

For records indicator 9, a random sample of a minimum of 50 patients (per GP practice) prescribed a repeat medicine was selected. Pharmacy technicians in the MMT then searched the patients’ medical records for evidence of a documented indication for that medicine. Of the 2,259 patient records reviewed almost all medicines (93 per cent) had a documented indication. However, where the indications were recorded was also noted; 40 per cent of these indications were documented deep in the consultation notes of the practices’ electronic system or in Lloyd George (handwritten) notes. It is, therefore, unlikely that this information would be readily accessible during a consultation, where a summary screen is usually used.

For medicines indicator 5, pharmacists in the MMT assessed the quality of 1,258 medication reviews undertaken by either GPs or nurses. The reviews were assessed using the Read codes applied, for example, 8B3x is used for a medication review conducted with the patient and 8B3h for a review conducted without the patient. How well the reviews were recorded was also looked at. Key findings include:

· Most medication reviews were conducted with patients (8B3x was the most popular Read code used).

· 24 per cent of patients’ records contained no information regarding the content of the medication review.

· Approximately 1,600 pharmaceutical care issues (mainly related to further monitoring requirements) were identified by the pharmacists. (This also indicated that the medication reviews conducted were lacking in pharmaceutical input.)

For medicines indicator 9, the quality of medication reviews in 10 groups of patients, each prescribed a different class of repeated medicine (see Panel), was assessed against set criteria. Of the 305 patients prescribed combined oral contraceptives, 25 per cent did not have their blood pressure checked before being prescribed the contraceptive and a similar proportion had not had their BP checked within the past six months. For the 252 patients prescribed hormone replacement therapy, BP checks, information on family history, explanations of associated risks and what to do if breast changes occur were poorly documented in their records.

Implications of key findings

The impact of the findings was two-fold. First, the MMT developed action plans to address issues specific to individual practices. For example, the MMT recommended that practices without a call and recall system for patients who require specific monitoring arrangements should develop such a system. The importance of ensuring that patients’ records are comprehensive and up to date was emphasised because of the increasing number of different health care professionals that are now directly involved with patient care. Second, the exercise enabled the timely launch of PCT-wide guidance for health care professionals on conducting medication reviews. This guidance was informed by “Room for review a guide to medication review”¹ and local work for the Medicines Management Services Collaborative. It provides information on the different levels of medication review, what should be considered at each level and the appropriateness of a range of Read codes. It also advocates the use of the medication review templates (not all practices use these) that are available on the clinical systems.

Reflections

Feedback from the GPs revealed that, on the whole, the QOF assessment work undertaken by the MMT was of value. Even with limited resources (people and time), a wealth of useful information was gathered. However, a number of important lessons was learnt from this exercise. The impact on the workload of the MMT was major — over the four-month data collection, three whole-time equivalents (about 10 per cent of the team) were required.

Guidance from the Department of Health was delayed and the PCT did not consult the MMT regarding its role in the QOF assessment process. This meant that there was limited time for the MMT to prepare for the work, including piloting audit work. In addition, there was little guidance regarding the level of detail required. With hindsight, it was probably unnecessary for the MMT to work to such depth for the purposes of the PCT assessment, because the reports informed only a small part of the QOF assessment process.

Unfortunately, some practices perceived the role of the MMT as one of policing and, in some cases, this resulted in the unravelling of relationships that the team had spent years building.

These lessons helped to inform how this year’s annual QOF assessment was conducted.

ACKNOWLEDGEMENT The assessment criteria were prepared by Sue Read, cluster prescribing adviser, and Catriona Clareburt, network pharmacist, both at Central Liverpool PCT.

References

1. Task Force on Medicines Partnership and The National Collaborative Medicines Management Services Programme. Room for review: a guide to medication review. London: Medicines Partnership; 2002.