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Verification visits


24 September 2012

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There is a sense of finality at the start of April when the data from the previous QOF year is signed off by the practice and submitted to the primary care trust (PCT) or health board.

Most of the payment has been made already. There is a bit more data to be entered by the PCT to make the final calculation of prescribing indicators but this is relatively small in the greater scheme of things.

There is a sense of finality at the start of April when the data from the previous QOF year is signed off by the practice and submitted to the primary care trust (PCT) or health board.

Most of the payment has been made already. There is a bit more data to be entered by the PCT to make the final calculation of prescribing indicators but this is relatively small in the greater scheme of things.

The PCT, and presumably next year the NHS Commissioning Board (NHS CB), is responsible for the money that is paid out to practices. NHS CB accounts need to be audited and so it must be able to say that the cash has been distributed correctly. Post payment verification is one of the methods by which this is done.

This has long preceded the current contract. Teams would previously descend on practices for days at a time to pore through sets of paper notes and verify item of service claims.

The same is true of the quality and outcomes framework (QOF). Visits, before or after payment, were almost universal in the first couple of years of the QOF. These have become less common as time has gone on although the practice of PCTs varies greatly. Assessments can vary from a paper exercise to a full visit with inspection of the practice records.

Fortunately this is now largely computerised. As the clinical data is extracted directly from the practice computer systems there is no need for further examination to confirm the existence of particular codes as these have been independently verified.

The review can concentrate on the way that codes have been applied and evidence of the application of protocols and procedures from the organisational domain.

While the particulars of the assessment are set by the PCT the QOF requirements are not. The guidelines are available from the websites of BMA and NHS Employers.

Here it’s quite specific about the what is required as part of each indicator and about the verification that would be expected as part of the confirmation.
These guidelines, alongside the business rules which govern the extraction of data from practice systems form the basis of any assessment of the practice QOF submission.

The actual payments are specified in the statement of fees and allowances published by the Department of Health. The PCTs have very little discretion in this national set process or payments.

This is an important point as there have been reports of PCTs attempting to apply their own criteria to the validity of the submitted data and the payments to be made.

The guidelines should give a degree of assurance to both sides about what is expected.

While local protocols and services will influence how treatment is given they should not have a direct effect on the way that QOF operates. Equally practices should not be penalised for adherence to local protocols. These may principally relate to the use of exception codes in prescribing indicators or where specific secondary care services are required for the fulfillment of indicators. Certain blood tests or other investigations may not be commissioned in some areas.

PCTs often have their own formularies and exception reporting policies should coincide with these. Often however these may be in separate departments and aligning these policies is not always automatic. The exception codes for maximal tolerated dose can often relate to the maximum dose tolerated by the local health authority rather than by the patient.

Co-ordination between commissioning policies and primary care contracting is imperative to avoid giving conflicting messages to practices. This may well become harder over the next year as these responsibilities are passed to separate organisations.

The most common area for verification is exception reporting figures. There is considerable variation in these figures between practices and they are often viewed with suspicion.

Most of the evidence suggests that practices use exception reporting reluctantly and only as much as is required. There are often quite small numbers involved which can lead to wide variation in percentages.

Verification of the exceptions, by either the practice or PCT, will require a review of the codes that have been entered. There are a large number of codes that can be used but practices should have a robust protocol that withstands scrutiny.

Exception codes are commonly grouped together under a “parent” code that simply states that the patient is excepted. While this will be acceptable under the business rules they are generally not considered acceptable at verification. Where a code is used it should be specific about the exception category which is being claimed.

While the business rules only look for the codes verification visits will also look at the context of the code and associated text to show justification of the exception. It is important that the reason for the exception is clearly stated.
In cases of drug allergy or explicit dissent by the patient the reasons tend to be clear.

Where the patient is regarded as unsuitable then the individual reasons for this decision should be given. In some cases these reasons may be continue to be valid from one year to the next.

Commonly patients are exception reported where there have been three invitations to a review or procedure. If there has been no response to three letters then the patient may be exception reported for a year, or five years
in the case of cervical screening.

There should be a clear record of the dates that the three letters were sent and which invitations that they contain. Cervical screening again is a little different as the first two reminders may have been sent from a central cervical screening services. There should be a procedure in the practice for verifying that this is the case and the date of the third letter recorded.

In general there are not Read codes available to record when each of these reminders were sent but free text or other recording systems would be sufficient.

Prevalence and the coding of disease diagnosis are likely to be examined. The aim can be an attempt to measure data quality by looking for differences from what has been predicted.

Trying to work out what prevalence is expected is a difficult task. There are estimates based on theoretical models which are used by sites such as NHS Comparators and by London PCTs. These are generally based on population studies and relate poorly to the observed prevalence. An alternative is simply to compare GPs against their neighbours and to identify outliers.

Neither of these systems is particularly accurate at the level of individual general practices. High prevalence may be caused by practices aggressively, but appropriately, searching out disease. Low prevalence may simply reflect a population with less chronic disease.

Variation in prevalence can suggest useful areas to examine at the time of a visit to the practice but it is not a significant finding in itself. At least one PCT has attempted to withdraw payment in cases of low prevalence. There is already a mechanism to alter payments based on prevalence that is part of the QOF and there should be no need to add to this.

Practices should be able to explain their criteria for entry to a disease register and how those registers are maintained. That may include running audits to make sure that all patients are correctly coded. This is normally in the practice’s interest anyway as larger register size will generally increase the QOF payment.

If a post payment visit is considered necessary this can be quite time consuming for the practice both in preparation and on the day itself. PCTs vary in their methods for choosing which practice to visit. It may be as simple as drawing names from a hat. Some PCTs may only visit statistical outliers and some may use a combination of both methods. The PCT should inform the practice of the reason that they have been selected.

The prospect of a visit can be stressful to practices and, at the least, is likely to take up several hours or time for a partner or practice manager. Good communication between the PCT and the practice before the visit can ensure that the visit feels less threatening to the practice and the assessors have access to the information and people that they need to see.

Assessment of the clinical indicators may require to access patient data. While there have been concerns about confidentiality in the past it is largely accepted that some access for the purpose of accurate management of public money is justified. Some anonymising is possible.

The simplest solution may be to set up a new user account on the practice computer system. This account should be able to see most of the records but to change as little as possible.

It should not, for instance, be able to issue prescriptions or add Read codes to the record. It may be possible to obscure patient name and address to some extent although in practical terms this may be limited. It is up to the practice if searches should be enabled or whether these would only be run by practice staff.

There should be no reason for patient identifiable data to be removed from the practice. The assessment should solely be of the adherence to QOF regulations.
Protocols and policies required in the organisational domain will likely have been submitted to the PCT some time before the visit. The aim of the visit is to examine how these have been implemented. This may involve questioning the receptionists at the practice and other staff. It is important that they are aware of the more common or important procedures and know where to look up others.

The systems for notes summarisation should be clear and the staff who summarise the notes should be able to explain how it is done and how queries are resolved.

The patient leaflet may be inspected as well as other information given to patients through posters or signs.

For most practices the thought of an assessment nvisit is about as welcome as a visit from the tax man.

Proving a negative is never easy and it can take a lot of effort to demonstrate that there is nothing wrong with the practice data. It is, however, and inevitable part of a public funded contract.

Work done to identify what is needed before a visit can pay off on the day. It is likely to save time in the long term and even prevent the need for a repeat visit.
In the end you can console yourself that it is unlikely to be you again next year!

Dr Gavin Jamie, Swindon GP, Webmaster of the QOF database

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