The role of the practice nurse in cancer care reviews

Recent changes to the Quality and Outcomes Framework provide an ideal opportunity to improve the quality of cancer care reviews and cancer patients' experiences. Sandra Dyer explains the important role practice nurses can play in improving care Improved outcomes for people diagnosed with cancer have led to increasing numbers of people living with and beyond the disease, and for many, cancer has transitioned to a long-term condition. There is a greater need for models of care that best meet these patients' needs, with the role of primary care becoming increasingly important. Recent changes to the Quality and Outcomes Framework (QOF) provide an ideal opportunity to improve the quality of cancer care reviews and improve cancer patients' experiences. More education and training for general practice nurses on cancer is urgently required to allow them to lead on quality improvement in this important area of care.

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study

Objectives England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions. Design Historical cohort study. Setting A total of 330 English primary care practices, 2010–2017, using UK Clinical Practice Research Datalink. Participants A total of 84,441 adults with type 2 diabetes. Main Outcome Measures The primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission. Results There were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89–0.92; p < 0.001 and 0.87; 95% CI 0.86–0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96–0.99; p = 0.001). Strong associations were found between completing 7–9 (vs. either 4–6 or 0–3) National Diabetes Audit processes and lower rates of all admission outcomes ( p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7–9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions. Conclusions Attaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.

Collaborative improvement in Scottish GP clusters after the Quality and Outcomes Framework: a qualitative study

Background: Scotland abolished the Quality and Outcomes Framework (QOF) in April 2016, prior to implementing a new Scottish GP contract in April 2018. Since 2016, groups of practices (GP clusters) have been incentivised to meet regularly, to plan and organise quality improvement (QI) as part of this new direction in primary care policy. Aim: To understand the organisation and perceived impact of GP clusters, including how they use quantitative data for improvement. Design/Setting/Methods: Thematic analysis, of semi-structured interviews with key stakeholders (n=17) and observations of GP cluster meetings (n=6) in two clusters. Results: There was uncertainty whether GP clusters should focus on activities generated internally or externally by the wider healthcare system (e.g. from Scottish Health Boards), although the two clusters we observed generally generated their own ideas and issues. Clusters operated with variable administrative/managerial and data support, and variable baseline leadership experience and QI skills. Qualitative approaches formed the focus of collaborative learning in cluster meetings, through sharing and discussion of member practices’ own understandings and experiences. We observed less evidence of data analytics being championed in these meetings, partly because of barriers accessing the analytics data and existing data quality. Conclusion: Cluster development would benefit from more consistent training and support for cluster leads in small group facilitation, leadership and QI expertise, and data analytics access and capacity. Whilst GP clusters are up and running, their impact is likely to be limited without further investment in developing capacity in these areas.

Data quality in primary care, Scotland

Background and aims This project explores primary care data quality (DQ) across Scotland. Methods and results A survey was sent to primary care staff in winter 2019. National data regarding Quality and Outcomes Framework (QOF) performance indicators and the GP software system used was obtained, analysed with T-tests and Chi-squared tests. Overall QOF performance with non-financial incentives from 918 practices was 77%. There was no significant difference with overall QOF performance against GP system ( p = 0.46) or if the practice had a coder ( p = 0.06). From the survey, search systems that make it hard to search for particular codes was the most important barrier to DQ; 61% of respondents ( n = 491) felt there was particular information GPs should code, 16% of respondents stated that hospital discharge letters generally include corresponding codes and 9% for outpatient correspondence; 43% stated their practice had undertaken steps to improve DQ, training was the most common initiative, followed by workflow optimisation, dedicated coder(s), audit, guidelines and using code lists; 80% ( n = 475) of respondents had received training in using their GP system, an average of eight years ago. Conclusion Obtaining improved GP systems, training, agreeing what GPs should code and improving transfer of data should be explored.

Quality and safety

This chapter covers quality governance, clinical audit, evidence-based healthcare, the Quality and Outcomes Framework (QOF), patient and public experience, complaints procedures, and clinical risk management. It includes professional conduct, the provision of anti-discriminatory healthcare, and consent. Professional accountability is outlined, as well as the role of chaperones, methods of whistleblowing, correct record keeping and access to records, confidentiality, and client- and patient-held records. Health and safety at work for both employers and employees is discussed, together with specific issues that arise with lone working in the context of community nursing. Personal safety measures such as hand washing and personal protective equipment are covered. Occupational exposure to blood-borne viruses and the appropriate response is described, as well as notifiable diseases, managing healthcare waste, and the management of sharps waste.

2017 Cancer Prevalence Dashboard for London

BackgroundAs cancer incidence increases and survival improves, the number of people living with a cancer diagnosis is increasing. People living with cancer have 50% more contact with GPs 15 months after diagnosis than a population of similar age, sex and locality; 70% have another long-term condition.AimTo aid service providers’ understanding of the cancer prevalent population by creating a publicly available visualisation tool that both describes patients’ demographics and length of time lived with cancer, and compares counts of nationally registered cancer survivors to GP-maintained registers.MethodUsing National Cancer Registration and Analysis Service (NCRAS) data, prevalence rates and counts were generated for London patients diagnosed 1995–2017 and alive 31 December 2017, overall and for lower-level geographies. GP-recorded Quality and Outcomes Framework (QOF) prevalence at Clinical Commissioning Group (CCG) level was compared to NCRAS counts for the same period.ResultsOn 31 December 2017, 231 740 (2.6%) people were living with cancer in London; 33% were diagnosed 5–9 years prior and 31% were diagnosed ≥10 years prior. Prevalence was higher in women (P<0.001) and dramatically increased with age for London (P<0.001); >12% of >75 year olds were living with a cancer diagnosis in every lower-level geography. Completeness of GP QOF cancer registers against NCRAS prevalence counts ranged from 75–108% across CCGs.ConclusionLocal understanding of the cancer prevalent population is needed, with a concerted effort to interpret large discrepancies between QOF and NCRAS registers, which may arise from differences in coding practice. Ensuring patients are identified in primary care is a first key step to managing cancer as a long-term condition.

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality. Objectives We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes. Design and setting We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome. Participants Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria. Interventions Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners). Main outcome measures Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care. Results Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care. Limitations There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences. Conclusions Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings. Future work Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

Demographic variation in fit note receipt and long-term conditions in south London

ObjectivesIntroduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.MethodsData were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.ResultsIn a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.ConclusionsFor the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

Improving Access to Psychological Therapies for older adults: auditing management of newly diagnosed mild and moderate depression in six general practices within the Birmingham and Solihull CCG

BackgroundThe first-line treatments for mild–moderate and moderate–severe depression according to the National Institute for Health and Care Excellence clinical guidelines for the management of depression in adults are psychological therapies followed by or alongside pharmacological treatment. We conducted an audit of patient records (as recorded by general practitioners (GPs)) to compare practice to the guidelines.MethodsIncident cases were retrospectively identified from electronic primary care records (SystmOne). From 40 320 registered patients, cases were identified based on previously coded new diagnoses of depression in the 2016–2017 and 2017–2018 Quality and Outcomes Framework (QOF) years. Patient notes were screened for exclusion criteria (mental health problems that would alter management pathway) and for records of management discussions (pharmacological or psychological therapies) at the diagnostic appointment.ResultsIn 2016–2017 (n=315), psychological therapies for depression were discussed at 63.2% of diagnostic appointments, they were most discussed at appointments with those aged 18–29 years (70.8%), but this decreased with age to 56.3% of appointments with those aged ≥65 years. In 2017–2018 (n=244), psychological therapies were discussed at 70.9% of diagnostic appointments but were discussed at more appointments with those aged 18–29 years (81.6%) and at less appointments with those aged ≥65 years (39.4%). Discussion of pharmacological management was similar for all age groups in 2016–2017 (89.9%) and 2017–2018 (93.0%).ImplicationsFor patients aged ≥65 years, psychological therapies are featuring less in management discussions with GPs or are not being recorded. Recommendations for change implemented at the practice included feedback of results and professional reminders throughout the 2019-2020 QOF year.