NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP

Primary Care Development Group.

27th July 2015

Report Title: / Update: Support for Quality Improvement Visits. / Item No:
Building upon the previously run Referral Medicines Management Team Visits (RMMT) the revised Support for Quality Improvement Visits (SQI) commenced in December 2014. The visits formed part of an area wide process to provide assurance of quality and performance in primary care.
Aims:
To hold up the mirror of data and get the practice to reflect on its performance Re. resource utilization; sharing best practice, learning from others and seeking to understand the information more completely in order to change where necessary.
To seek assurance as a CCG on the quality of primary care as delivered through the identified themes:
  1. Health Outcomes – GP Practice Profiles
  2. CCG determined clinical audit – 2014/15 – GRASP AF
  3. Intra Practice Variation
  4. Unavoidable admissions
  5. Integrated Care
  6. Lay Representatives decided theme
Outcomes:
Reduce Clinical Variation. A mechanism for encouraging practice development and sharing good practice.
This paper sets out a review of the visiting programme 2014-2015 and key areas from aaplanning meeting attended by clinicians, practice managers and CCG staff involved in in the programme.
All practices have been visited and visits followed a set agenda; practice data viewed included Locality and Practice detail packs, patient survey, Public health practice information and the Diabetes pack. The locality and practice detail pack compared referral data, elective admission data, emergency admissions and A&E activity and Out of Hours activity. Three years’ worth of data was presented broken down to locality and practice level. This provided the opportunity to discuss any significant variance with practices and to further drill down into the detail of the data. As a result of this information many practices agreed to conduct their own in house audit in areas highlighted to determine the reason for the variance.
A new element within all meetings has been a joint medicines management/ clinical quality focus on the management and treatment of Atrial Fibrillation (AF). This has been in response to the commissioning for value pack presented last year which highlighted that the Prevalence of stroke or transient Ischaemic attacks (TIA) were significantly higher in North Derbyshire than the 10 comparator CCGs used within the comparison.
Prior to each visit an in house audit was conducted which reviewed the number of patients with risk factors for AF; this included a breakdown of anticoagulant and antiplatelet usage. This was discussed at all visits and practices were asked for details of how they would review patients highlighted as needing a management review. To support practices in undertaking this work Joint QUEST sessions were based upon Atrial Fibrillation and Heart Failure.
The patient survey was been presented in a new format which compared a two years’ time frame and CCG ranking, this instilled much discussion about access to services and actual versus perceived access challenges. Many practices continue to work with their PPGs and produce in house surveys as well as the national survey which reflects the thoughts of patients attending the practice. Practices have installed additional phones, introduced new systems such as GP First, worked with PPG to develop patient charters and developed practice values to support accessibility. One practice has developed a set of practice values which are integral to all decision’s now made by the practice and have built this into all appraisals.
The Public Health Practice information presented a range of practice level indicators which included the Quality and Outcome Frame domains; this was compared with both the CCG and National average. The profile also covered deprivation and local demography; this provided the opportunity to look at previous data and information presented within the profile in comparison with local social and health statistics.
The visit also focused on a planned care topic which for the past two years has been Diabetes. Each practice was presented with a personalised booklet with the aim of aiding practicesto reviewdiabetes care/ support improvement and share good practice. Booklets covered the following areas: practice data (prevalence, 9 key care processes, Hba1c target, BP target, cholesterol targets, QOF exemptions, Diabetes and You referrals), medicines management, hospital activity, CCG position, foot care profile and patient survey.
As part of planning for the SQI visits for 2014/15 an overview of the process was presented to the Lay Reference Group. The group was asked to put forward a theme they would like a focus on during the visit, after discussion the following two themes were included:Healthy Lifestyles and Medication Reviews. Both questionscreated discussion within the meetings. Practices promote healthy lifestyles in many differing ways ranging from discussion within chronic disease management reviews, hosting an in house health trainer to participation in community events such as supporting local school health days. All practices carry out medication reviews and most consider that evaluation is based upon individual outcome, many practices thought this was a very interesting question with one deciding to conduct a review of patient perception linked to medication review. A full report will be submitted to the Lay Reference Group.
Visits were carried out over a six months period ending in May, a meeting was held in June to discuss what had gone well with the visits this year, what could have been improved and how the visits could be further developed for next year.
What worked well?
-The change in focus from referrals to GRASP AF and Diabetes was thought to be beneficial.
-Information at SQIV covered a wide aspect of regular Practice work.
-Enhanced services – not a monitoring role but visits allow for problem solving, asking of questions and practices able to ask for support if needed.
Value and impact of visit on Practices and visiting doctors
Visit gave time for the practice to reflect, even forced reflection that was beneficial, ‘a big plus’.
More supportive as discussion was on how the CCG could support to improve. However, it also depended on the engagement of the individual Practice.
SQIV information and post action plan can support GP appraisals and can be used within CQC visits to demonstrate continuous quality improvement.
Forward Plan
SQI visits will now take place on a 2 year course on a rolling basis.
The visits will become more individualised to practices, there will be an overarching agenda but areas covered within this will differ from practice to practice.
  • A review of actions from 2015/15.
  • GRASP AF and CKD/AKI in future agenda.
  • Procedures of Limited Clinical Value referral data.
  • Practices to choose areas of interest from the monthly data pack and examine in detail. Practices to select 3 procedure specific areas where they are above/below average and to show how they have improved/can improve allowing for practice ownership.
  • Enhanced Services.
  • Two Lay Representative identified Themes.

2. / Key matters for consideration
To support the continuation of visits.
Consideration and agreement of the areas to be covered in 2015/16 visits.
Agree with the move to a two year rolling programme.
3 / Financial Impact
SQI Visits are included in the Engagement Fund and are costed at -
36 Visits with GP for 4 Hours ( preparation,pre meet, travel plus 2 hr meeting) = 11,520
4. / Analysis of risk
To hold up the mirror of data and get the practice to reflect on its performance Re. resource utilization; sharing best practice, learning from others and seeking to understand the information more completely in order to change where necessary.
5. / Equality Impact
Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely:
Better health outcomes for all:
The aim of Support for Quality Improvement is to hold up the mirror of data ( from audit) and get the practice to reflect on its performance Re. resource utilization; sharing best practice, learning from others and seeking to understand the information more completely in order to change practice where necessary.
Improved patient access and experience:
One of the practice decided topics is to ask the practice patient participation group to decide a theme to be discussed within the visit. The Lay Reference group will be asked toprovide a theme.
.
Empowered, engaged and well-supported staff:
Practices can include members of staff within the visit/ share report and include all staff members in any practice development as a result of the visit.
Inclusive leadership at all levels:
Practices will be requested to share the visit discussions within the practice and can invite if wanted other team members to the visit.
6. / Recommendations
The PCDG provides support for the suggested changes to the identified themes as listed in the Forward Plan.
Author: / Judy Derricott
Sponsor: / Marie Scouse
Date: / 13.07.15

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