Somerset Practice Quality Scheme Learning points to assist other areas
1.1 Somerset introduced a local alternative to the national GP quality incentive scheme (Quality and Outcomes Framework), in 2014. The Somerset pilot is regarded by NHS England as an early pilot of co-commissioning arrangements. This brief paper is intended to help colleagues in other areas who wish to learn from the Somerset experience. It reflects the views of the SPQS steering group, which includes the three organisations involved; Somerset Local Medical Committee, Somerset CCG and the NHS England Bristol, North Somerset, Somerset and South Gloucestershire Area Team.
1.2 This paper should be read alongside the following documents which are included in the briefing pack: SPQS Briefing Paper which describes the scheme, SPQS Evidence Paper which summarise the research evidence about QOF and possible alternatives, Quarter 2 Progress Report, and SPQS Evaluation Plan showing the measures being used to evaluate the scheme. The interim evaluation report will be produced in late January. This paper therefore focuses primarily on what the process we have been through can tell us, after giving a handful of examples of the work that Somerset GPs have been doing so far.
2 EXAMPLES OF SPQS WORK
2.1 Three small practices in West Somerset are working together to provide enhanced end of life care at home for people in very remote rural communities. The nearest acute hospital is an hour away even by ambulance. A nurse has been employed to provide proactive, comprehensive care and works extremely closely with the GPs.
2.2 Taunton Deane Federation of GPs is organising multi-disciplinary multi-agency review meetings for patients with multiple long-term conditions who are frequent users of health services. The aim is to review their care and ensure that they are supported to manage their own health.
2.3 Practices in Chard, Ilminster and Crewkerne are working closely together to develop a model of a shared nursing team between the practices.
3 KEY LEARNING POINTS FROM THE PILOT SO FAR
3.1 The relationship between the CCG, LMC and Area Team was crucial. The relationship could be described as mature and open to innovation. The pilot would simply not have succeeded without this. Where relationships are not as strong, it would be wise to start with small collaborative projects before embarking on a major innovation.
3.2 There are multiple definitions of quality in general practice. The biomedical protocol based approach to general practice is one approach and not without merits, but there are others. It is important that alternative schemes give local clinicians and other stakeholders the time and space to think about what they mean by quality.
3.3 GPs in Somerset told us that they wanted better joined-up care for their patients, and the opportunity to innovate, free from specification and direction. We therefore had a clear starting point.
3.4 The views of patients are also critical. In Somerset we took the view that as QOF was focused on long-term conditions management the alternative scheme should also focus on this area of general practice. We had good information available through our long-term conditions programme about what patients wanted.
3.5 The time needed to design an alternative cannot be underestimated. The Somerset pilot only had three months for the design phase, which was very tight but not impossible. A longer design and consultation period would have been helpful in allowing more detailed engagement with stakeholders.
3.6 The research evidence is clear that the acceptability of measures to clinicians is an important success factor in quality improvement projects. Much of the solid evidence base for QOF has been tarnished by the link to practice income and the imposition of new targets that were not supported by clinical consensus. The selection of measures is therefore vital.
3.7 Our approach to incentives tends to focus on financial incentives. This is odd because the research evidence shows that health professionals are primarily motivated by other types of incentives. In particular, we found that a strong incentive for general practitioners is a satisfying working day with a manageable workload. Consideration of incentives in a broad sense is therefore important.
3.8 QOF is ubiquitous as a data source for general practice. This has a number of effects; it provokes challenge about the quality of clinical care under any alternative scheme; it makes it important to clearly set out what alternative measures are proposed; and it means that continued participation in data extraction from GP clinical systems is essential to serve secondary uses such as national clinical audits.
3.9 A clear set of evaluation measures that attempt to describe the relationship if any between the intervention and outcomes are essential. Independent evaluation, possibly through an Academic Health Science Network is important.
3.10 For the membership of the CCG and LMC, deviating from the national GP contract settlement was a big step, and they faced considerable criticism from some colleagues involved in national negotiations. Although many GPs have concerns about the prospects for the national contract, there is still reluctance to leave it. Local alternatives need to be more attractive than the standard GP contract option. The co-commissioning guidance is helpful in this respect as it sets out that the standard GP contract framework will still be available and any alternative local schemes are purely voluntary.
3.11 For some colleagues used to the specification of QOF, the pilot scheme was challenging. Some colleagues in the CCG had particular concerns about how on-going quality would be measured and assured. Any alternative scheme needs widespread support not just across CCGs, LMCs and Area Teams but within those organisations.
3.12 The level of resource devoted to the pilot has been considerable, with the CCG hosting a full-time project manager accountable to the steering group, and significant amounts of senior level time in the LMC, Area Team and CCG being spent on the pilot. The design of alternative schemes needs to address the resources required to implement it.
3.13 The final specification for the Somerset pilot responded to the calls for autonomy and freedom to innovate. However some colleagues found the very open nature of the contract to be anxiety-provoking. It may be that there was an element of sample bias if those GPs and Practice Managers who engaged most thoroughly in the design process were very comfortable with a low level of specification. A number of practices declined to take part in the pilot as they were not satisfied that the criteria for receiving payment had been sufficiently thoroughly described.
3.14 The Somerset pilot has three strands- clinical care; integration projects and sustainability projects. The projects were intended to allow the development of new models, freeing up the innovation and creativity of general practitioners. This has worked to an extent, and the pilot is still ongoing, so it is too early to judge, but there was a feeling of having to scramble around for project ideas among some participants. In retrospect, the clinical care within the consultation feels the most important part of the pilot. We started off wanting to preserve clinical quality once QOF incentives were removed but we now want to actively promote person-centred care in the consultation. A focus on the consultation might be a good conceptual starting point for any alternative scheme.
3.15 Allied to this focus on the delivery of person-centred care, we have become much clearer about what we need to measure in a person-centred care system. It is now broadly accepted that measures of process and activity are not suitable and instead a suite of measures including patient activation, patient outcome, patient experience and clinician/ staff experience are required.
3.16 Many colleagues working in general practice have reported increased morale as a result of the pilot. Reasons given include a sense of being listened to, greater opportunities to practice person-centred medicine and a reduction if activity with little perceived clinical value.
4.1 The Somerset pilot is very much work in progress. The final evaluation report is not due until July 2015. However we hope that the learning so far from our pilot is of some use to colleagues in other areas considering alternative incentives schemes.
4.2 For further information please contact Michael Bainbridge, Somerset Practice Quality Scheme project manager, email email@example.com phone 01935 384037