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The QOF: how was it for you?

Benny Harston
SRN SCM DipNurs BSc(Hons)
Nurse Practitioner
Hoveton Surgery, Norfolk

Looking back over the last year I am amazed at how quickly it has gone, and I suspect that it was in part due to the frenetic team effort that began last April 2004 when we started the task of collating information towards gaining our quality and outcomes points as part of the new contract.
I work as a nurse practitioner in a rural practice in the heart of the Norfolk Broads. We are a dispensing practice with 8,500 patients. Clinical staff consists of five whole-time GP partners, three nurse practitioners, two practice nurses, a healthcare assistant and two GP registrars. We have a practice manager, practice administrator, secretaries and receptionists. We have moved into a new PFI (private finance initiative) purpose-built surgery in the last two years, and it is really superb to work in such spacious surroundings.
The whole practice team have been involved with achieving the QOF points, and I cannot imagine that it could be any different. One of our GPs was leading on the new contract and had time out of surgery in order to organise a cunning plan. Information technology (IT) was a crucial part of achieving our targets and monitoring our progress.
We are fortunate in having an IT manager. He set up various programmes that could identify tasks that needed doing, which pop up on the desktop while the clinician is consulting. It was useful, if sometimes irritating, to have a little box filling the screen asking you to do a blood pressure, record smoking status, check cholesterol, and so on, and deflected from the reason for the patient's visit if you were not careful!
We had regular team meetings looking at our progress. Bar charts that looked a little like the church donation fund were regularly produced as encouragement, and meetings set up with individual groups to decide on tactics for dealing with therapeutic areas that may not always have been as high on our priority list as other more high profile conditions.
Initially it was difficult to identify what we needed to do, as past recording of clinical information and Read coding patients' significant morbidity was not as robustly documented as desired. Patients whose computer summaries were not up to date had to have their notes drawn and information then Read coded onto the computer. This generated an enormous amount of work. However, this was time well spent as it enabled the computer notes to be brought up to date.
The new contract has certainly raised the profile of chronic disease management and has provided a minimum standard of care. Like many practices we thought we were doing very well looking after our patients with chronic disease. However, we found many patients whose care could be improved. Inviting patients in who tended to have bypassed the system also provided opportunities for health promotion intervention, and our smoking cessation clinics are usually full nowadays! We also found a huge increase in the demand for phlebotomy generated by the necessity to get cholesterols and other bloods checked.
There are concerns that we will be so busy trying to get patients' disease markers to the optimum level that their holistic care will suffer. Patients do not and will not fit into boxes, thankfully, and there will be targets we can't meet without detrimentally affecting patients' lives - for example, a hypertensive patient who cannot tolerate polypharmacy to reduce their blood pressure because of unacceptable side-effects.
For the future I hope that practices will follow the recommendations of the new contract by rewarding their whole practice team for the sterling amount of effort and work that will be needed to sustain the benefits of the new contact.

Susan Hoskins
RGN RM
Practice Nurse
Pembroke Road Surgery, Bristol

Was I the only person searching for those last few elusive smears on 31 March this year? With a practice size of over 9,000 you do need to do a lot of smears to hit the target of 80% of women aged 25-64 who have a recorded smear in the last 3-5 years; but my patients are mainly well off, well informed and well educated, so we were surprised to discover that we might just miss our smear target.
We aimed for maximum points for everything. We are a PMS practice based in the desirable Clifton area of Bristol. We are also an EMIS practice and so have the advantage of using the population manager facility to monitor our QOF progress, but I personally found this first year of working to targets challenging. I suspect our smear target was difficult to achieve because we had failed to record the odd smear when summarising notes in the good old days before NICE and the NSFs, and also because of the "ghosts" - those very compliant patients who never trouble you with awkward phone calls at 6pm on Friday but who don't attend for their smears either because actually their last consultation was well over five years ago, just before they moved away!
We had a bit of a crisis when there were just a few weeks left to bring the points home and we realised that we had to hit the 80% target to get any of the 8 points allocated for up-to-date clinical summaries. We found ourselves sitting on 79% for day after day simply because of our practice size. Having made maximum points our goal, losing 8 whole ones simply wasn't an option, and so suddenly we all became summarisers! This encouraged team spirit, but it also resulted in an increased workload as the GPs unearthed patients who should have been on the CHD or asthma registers or who had not completed various investigations.
I am sure that GPs everywhere would have struggled to achieve the QOF clinical indicators without a large amount of practice nurse input and initiative. Although we were doing all the things already, it was doing all of them all the time and occasionally at the same time where we nurses really excelled. How many poor patients came in for a diabetic check and went out having had a smear and their peak flow function recorded as well! I did start to worry that we were becoming QOF-driven at the expense of the patient. Should I really be telling a sprightly lady of 98 to eat less butter because her cholesterol level was over 5? And did we really need to start her on a statin?
At some point during the year I discovered that, thanks to QOF, our nurse-led coronary heart disease (CHD) clinic was now responsible for the stroke/transient ischaemic attack (TIA) checks as well. My CHD training hadn't prepared me for this, but "somebody had to do them".
Some targets were relatively easy to achieve. We sent all the recorded smokers on all the registers an invitation to our smoking cessation clinics, instantly scoring 100% for having offered smoking advice. But some  targets needed to be approached carefully - how do you ask a 14-year-old asthmatic if he smokes when his mum is in the room?
Some targets were particularly difficult. Take retinopathy screening for diabetics. This is fine if your PCT provides a screening service. Ours doesn't, so we had to encourage patients to visit the local optician and check the results got sent back to us. The QOF standard here is set at 90%, which is virtually unachievable without a nationally available retinopathy screening programme.
We worked hard as a team all year and were very pleased with the results. Points mean prizes, and the QOF will have brought a lot of extra money into GP practices everywhere. If the hard work is to carry on I suspect many nurses will be hoping for some sort of financial incentive if they are to do it all again next year.