QOF2 emphasises the importance of regular significant event reviews and learning from your practice's experiences, explains Dr Nigel Watson


   

The requirements for the education and training indicators in QOF2 have not changed significantly;1 however, each practice should review the requirements and build on their previous experience.

Changes to the indicators

The two indicators that have been removed are Education 2 and 3, which required practices to undertake a minimum of six significant event reviews in the past 3 years and to perform annual nurse appraisals. These appraisals were already part of Education 8, which requires each nurse's learning plan to be discussed at an annual appraisal. This meant that a total of 6 points were available for redistribution.

The new indicator is Education 10, which requires the practice to undertake a minimum of three significant event reviews in the past year, and has been allocated all of the redistributed points in this section. Significant event reviews have, therefore, increased in importance and the points value has increased from 8 to 10 (Table 1).

Table 1: Education and training indicators in QOF2
Indicator no
Clinical indicator
Points
EDUCATION 1
There is a record of all practice-employed clinical staff having attended training/updating in basic life support skills in the preceding 18 months
4
EDUCATION 4
All new staff receive induction training
3
EDUCATION 5
There is a record of all practice-employed staff having attended training/updating in basic life support skills in the preceding 36 months
3
EDUCATION 6
The practice conducts an annual review of patient complaints and suggestions to ascertain general learning points, which are shared with the team
3
EDUCATION 7
The practice has undertaken a minimum of 12 significant event reviews in the past 3 years, which could include:

 

 

4

  • Any death occurring in the practice premises
  • New cancer diagnoses
  • Deaths where terminal care has taken place at home
  • Any suicides
  • Admissions under the Mental Health Act
  • Child protection cases
  • Medication errors
  • A significant event occurring when a patient may have been subjected to harm, had the circumstance/outcome been different
EDUCATION 8
All practice-employed nurses have personal learning plans, which have been reviewed at annual appraisal
5
EDUCATION 9
All practice-employed non-clinical team members have an annual appraisal
3
EDUCATION 10
The practice has undertaken a minimum of three significant event reviews within the past year 6
6

Resuscitation training

Basic life support skills are important for all staff, not just the clinicians.The interval for training is pragmatically set at 18 months, as it is recognised that skills need updating regularly.

Some practices have found that targeted training is the most appropriate as, for example, GPs will need a higher level of training than receptionists. They, therefore, hold an annual resuscitation meeting divided into two sections:

  • a basic session for non-clinical staff
  • a more advanced session for the doctors and nurses.

It is virtually impossible to get all the staff from the practice to be present at one meeting, so some practices have arranged to have meetings at 6-monthly intervals.

Resuscitation training is often available through the local NHS Trust's resuscitation office. Alternatively, some pharmaceutical companies may arrange for specialist companies to carry out this training. During the past 2 years, I have experienced both training methods and have found them to be of a high quality and very informative.

Resuscitation guidelines are readily available,2 updated regularly, and should be reviewed annually.

It is worth considering appointing a practice lead for resuscitation who can coordinate training, perhaps provide training for those who have been unable to attend the resuscitation training and ensure the practice has an agreed resuscitation protocol.

The protocol should include basic details about chest compression and respiration, and also information on using a defibrillator and which drugs should be used under certain circumstances. Hopefully these drugs will be used rarely, so someone should be responsible for checking expiry dates regularly and renewing stocks as appropriate.

Defibrillators

Some practices have been reluctant to purchase a defibrillator because of the cost involved and the complexities of use. Defibrillators are now considered a standard piece of equipment that should be present in all practices, and a practice could be criticised if a patient collapses and dies in the surgery and a defibrillator is not available.

Defibrillators can now be purchased for less than £1000 and are also fully automated, which means that they can be operated safely by a member of the general public.

Induction training

General practice has not only become more complex for the clinical staff but also for all other staff members. Reasons for this complexity include:

  • wider range of clinical conditions seen
  • more investigations and treatments available
  • more complex regulations
  • new IT systems, e.g. Choose and Book
  • clinical governance issues.

All practices should have an induction book for new staff as it was a requirement for QOF13 – it is now worth reviewing and updating this manual. Consider sharing yours within a local practice managers' group and see what you can learn from other practices. PCTs have reported to Local Medical Committees (LMCs) that some of these manuals are of high quality but others are basic and of little help.

Recently, a practice was taken to an employment tribunal and a staff member was awarded £30 000. Following this award the practice reviewed its procedures and concluded that if the induction training had been better, the issues in this case could have been avoided.

Complaints

Wessex LMC covers 3500 GPs in 430 practices,working in 19 PCTs. It was common for the LMC to be contacted by practices asking for help in handling complaints. However, with the introduction of in-house complaints procedures there has been a significant fall in the number of practices contacting the LMC. This is thought to be mainly because complaints are handled well by most practices and resolved locally wherever possible. Many patients making complaints are looking for two results:

  • first, for someone to say sorry
  • second, that lessons are learned from their experience

Saying sorry that an event has occurred and showing compassion and consideration for an individual is not the same as admitting guilt. In addition, explaining to the complainant that the lesson learnt from the complaint will be shared with others and that there will be change as a result may well be enough to satisfy them. It is, therefore,important not only to see what lessons can be learnt but also to look at all the complaints made in a 12-month period.

I was recently helping a 'dysfunctional practice' Ð on reviewing their complaints over a 12-month period it was clear that 50% of complaints related to the attitude of one GP and one member of staff. The result of their behaviour had a huge impact on the rest of the practice. When the evidence was presented to these two staff members, changes in behaviour were made, and the practice is now working more efficiently. As a result of identifying underlying problems patient care has also improved.

Significant event reviews

Significant event reviews are carried out regularly in most practices. Some practices solely focus on things that have gone wrong, but it is important to remember that lessons can also be learnt when discussing events that have gone well. Consider asking your practice staff the following questions:

  • Do all members of the practice understand what a significant event is?
  • Do all members of the practice know how to report and record the event?
  • Are significant event meetings held regularly?
  • Are significant event meetings restricted to GPs or are they multidisciplinary?

When holding a significant event meeting, ensure that those presenting the events are suitably prepared.The environment should be supportive and learning, not threatening and blaming – highlight the aspects that demonstrate high standards before looking at the standards which can be improved. After each discussion, the practice should conclude with one of the following:

  • confirm high quality care and congratulate those involved
  • no change is required, all appropriate action was taken
  • more information and possibly an audit are required to establish further details and the extent of the issue
  • change is required Ð agree the change and timescales involved, and also set a review date to ensure that the change has been fully implemented.

Conclusion

None of what has been described above is 'rocket science', but with the pace of change in general practice there always seems to be more important issues to deal with. At times of financial crisis, investment in education and training is usually the first area to suffer.

This is extremely short-sighted as we all require motivated and well-trained staff to deliver a very challenging agenda. In addition, any investment in this area may prevent significant problems at a later date.

Some practices have complained that this section of the QOF is of little value and is just a tick box exercise to achieve additional funding. This is a view that I do not accept. If you look at practices that have embraced education and training, and have fully implemented these indicators, they have found that the GPs, nurses, nonclinical staff and patients, not to mention the most significant player in this section – the practice manager, have all significantly benefited from this.

 

Guidelines in Practice, August 2006, Volume 9(8)
© 2006 MGP Ltd
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  1. British Medical Association. Revisions to the GMS contract 2006/2007: Delivering Investment in General Practice. London: BMA, 2006.
  2. www.resus.org.uk
  3. British Medical Association. Investing in General Practice: The New GMS Contract, supporting documentation. London: BMA, 2003.