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Rapid Responses: Rapid Responses published:
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Confounding variables
- Gwion Rhys (18 February 2006)
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Misleading study
- Peter MR von Kaehne (19 February 2006)
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Larger means for peer review
- Graeme M Mackenzie (21 February 2006)
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PMS difference for Lower QoF Scores
- John S. Ashcroft (24 February 2006)
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premature conclusion
- robert fleetcroft (27 February 2006)
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Gwion Rhys, General Practitioner Ty Doctor, Nefyn, Gwynedd, LL53 5BL
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I feel that confounding variables have been omitted from the above study. The first question is if measured quality is an accurate indicator of quality. In particular; accurate readcoding and data entry is vital for scoring highly in a GP’s contract indicators. In a larger practice with more staff, it is statistically more likely that they already had an IT guru; which is a vital part of scoring highly. Secondly, is the use of exception reporting, which is not mentioned in the study. A practice that excepts a proportion of the population from the data measurement will be achieving the same clinical results as a practice that uses little or no exception reporting. But a larger practice with more organised administrative staff can legitimately maximize their financial gain and points by the use of exception readcodes. Holistic points should also not have been included in the study. Holistic points are entirely dependent on the points achieved on the third lowest clinical domain; the same clinical markers are therefore included twice in the statistical analysis. Many small surgeries have no patients taking lithium makes them ineligible for any of the 11 related contract points. This is a further confounding element; which also adversely impacts the holistic score; and compounds any statistical error. I therefore feel that it's premature to conclude that small practices are incapable of providing the highest quality clinical care. Certainly I do not feel the paper robust enough to make future commissioning judgments about primary care. As the limited staffing resources of smaller practices have now had time to adjust to the challenges of the new contract; I strongly suspect that the gaps will have narrowed when practices are re- assessed in April. Competing interests: General practitioner in a small practice |
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Peter MR von Kaehne, General Practitioner Lochgoilhead Medical Centre, Lochgoilhead PA24 8AA
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This article makes a few assumptions which should not go unchallenged. The Quality Outcome Framework is essentially a measure of recording care and only secondarily one of care itself. It is by no means certain that high QOF scores are indicative of quality medical practice. The study did not investigate the role of clinical software - which according to all accounts is crucial. GPASS, the most commonly used clinical system in Scotland is atrocious and well known for its ability to mess up QOF scores. EMIS and Vision appear to have had their own issues, but not of the significance and seriousness most GPASS users I know describe. The same clinical action entered via a different screen might appear or might not appear. Some of these issues have been ironed out over the course of the last year, many have not. Further - and importantly - participation in the QOF process is voluntarily and requires a huge amount of commitment and work. The majority of this work has very little to do with improving actual medical care, but a lot with altering processes of data recording to make medical notes compliant. The care might have happened, but unless recorded in exactly the way QOF requires it will not count to one's QOF scores. Subsequently a number (maybe more smaller practices or practices with older doctors?) might have simply decided it is not worth their while to change their established working practices. Finally and most crucially, a lot of QOF scores require that the practice actually has qualifying patients for any particular indicator. If there are no patients in one particular category in this particular year then the practice will not obtain QOF points in this area. This is a well known issue for small practices and will prevent most from scoring "top marks". The paper makes no note of this. Competing interests: None declared |
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Graeme M Mackenzie, GP Whitehaven CA28 7RG
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Do larger teams perform better because organisation members feel more exposed to review of their work? They are therefore less likely to drift from accepted practice. They also will be exposed to the "different" approaches of attached staff and are more likely to be exposed to individuals taking a special interest in an area of care, acting as a motivator to do things better. Smaller teams may be more likely to collude with each other that what they do is "fine". Competing interests: None declared |
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John S. Ashcroft, General practitioner and Deputy Chair of Derbyshire LMC Old Station Surgery,Heanor Rd, Ilkeston, DE7 8ES
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Dear Sirs, Matt Sutton and Gary McLean's article is potentially misleading with its conclusion that practices with "lower income from other sources" maybe more incentivised to recorded higher quality. A view reiterated in the box "What this study adds" with the statement "Incentivised quality is higher for practices more likely to respond to financial incentives" A casual reader may interpret the statement "income from other sources" as being private income, but in fact represents differences in global sum". These differences in global sum can be substantial. Evidence obtained under the Freedom of Information Act by Derbyshire LMC show that the difference in global sum payment per patient is very largely due to differences between the practices' PMS and GMS status. The PMS practices receiving substantially higher levels of funding per patient than GMS practices. Quality scores in Derbyshire also show similar negative correlation to global sum funding per patient as seen in this study but the differences are entirely confined to PMS practices. This is to some extent confusing in that the extra funding to PMS practices for staff should be targeted in such a manner that should have well prepared PMS practices for high Quality scores, such as the preparation of disease registers, such as for coronary heart disease. It may be seen as being unclear as to precisely what PCTs and the tax payer is receiving for this extra funding. The answer may be found in the caveat (and warning to PCTs who may be considering reducing PMS payments) that there is a strong trend for increased levels of funding to areas of deprivation under PMS, whereas under GMS the trend is to the reverse, at least in Derbyshire. Competing interests: General Practioner in a GMS funded practice |
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robert fleetcroft, honorary senior lecturer in primary care, UEA school of medicine, health policy and practice UEA Norwich, NR4 7TJ
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dear Editor, this paper concludes that if generalisable, "to maximise (their) cost effectiveness....the structure and resourcing of primary care providers of medical care should be the focus of policy makers seeking to improve quality(1). The evidence provided by the paper however appears incomplete. The definition of quality is performance in the clinical domains of the new GMS contract. However this only measures part of the quality spectrum for primary care activity. Major established primary care interventions such as warfarin in atrial fibrillation are entirely omited (2). Prescribing cost does not seem to appear in the calculations, and these account for a significant proportion of the primary care budget. Therefore the conclusions regarding cost effectiveness and quality seem to apply to only a narrow part of the primary care spectrum and it is premature to change policy in this respect. 1. Sutton M, McLean G. Derterminants of primary medical care quality measured under the new UK contract: cross sectional study BMJ 2006;332:389-390 2.McColl A, Roderick P, Gabbay J, et al Performance indicators for primary care groups: an evidence based approach BMJ, Nov 1998; 317: 1354 - 1360 Competing interests: None declared |
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