Dr Nigel Watson discusses the practice management indicators, and details how new guidance on instrument sterilization may impact on procedures


 

   

The practice management component of QOF2 has remained unchanged from QOF1 in terms of the requirements.1 In QOF1 there were 20 points available, however, this has been reduced to 17.5 points in QOF2 (Table 1).

Some may have the view that if a practice achieved the maximum points available in the last financial year, no further work is required – but there are three reasons why practices should consider reviewing this organizational domain:

  • significant developments have occurred in the areas of child protection and arrangements for instrument sterilization
  • procedures may not be adhered to, so it is wise to review them before the PCT reviews your QOF achievements
  • some PCTs have been more lenient than others in their interpretation of QOF1. With the current financial pressures in the NHS, it is expected that PCTs will be much stricter in their interpretations of QOF2.
Table 1: Practice management indicators in QOF2
Indicator no.
Clinical indicator
Points
Management 1
Individual healthcare professionals have access to information relating to child protection
1
Management 2
There are clearly defined arrangements for backing up computer data, back-up verification, safe storage of back-up tapes, and authorization for loading programs where a computer is used
1
Management 3
The hepatitis B status of all doctors and relevant practice-employed staff is recorded, and immunization recommended if required in accordance with national guidance
0.5
Management 4
The arrangements for instrument sterilization comply with national guidelines as applicable to primary care
1
Management 5
The practice offers a range of appointment times to patients, which as a minimum should include morning and afternoon appointments five mornings and four afternoons per week, except where agreed with the PCO
3
Management 6
Person specifications and job descriptions are produced for all advertised vacancies
2
Management 7

The practice has systems in place to ensure regular and appropriate inspection, calibration, maintenance, and replacement of equipment, including:
– a defined responsible person
– clear recording
– systematic pre-planned schedule
– reporting of faults

3
Management 8
The practice has a policy to ensure the prevention of fraud, and has defined levels of financial responsibility and accountability for staff undertaking financial transactions (accounts, payroll, payment of invoices, signing cheques, petty cash, pensions, superannuation, etc)
1
Management 9
The practice has a protocol for the identification of carers, and a mechanism for the referral of carers for social services assessment
3
Management 10
There is a written procedures manual that includes staff employment policies, including equal opportunities, bullying and harassment, and sickness absence (including illegal drugs, alcohol, and stress), to which staff have access
2

Management 1

The value of this indicator remains the same at 1 point.

GPs have always had a legal and professional responsibility to take any necessary action to safeguard vulnerable children. GPs should ensure they are in a position to defend any accusation that they failed to take appropriate action in the event of a child suffering as a result of not providing suitable care. Since the Laming report,2 it has become quite clear that GPs are expected to work in close collaboration with other professionals involved in child protection.

If a GP believes a child to be at risk, the needs of the child are always paramount and override the duty to maintain patient confidentiality. GPs must cooperate with local procedures and demonstrate to their PCT that they are fulfilling their statutory obligations.

Section 11 of the Children Act 20043 clearly sets out that PCTs and Strategic Health Authorities must ensure that any services provided by practices have due regard to their new legal obligations. The new duties regarding child protection extend to all GPs and have been in effect since October 2005.

Since April 2006, new Local Safeguarding Children Boards (LSCBs) have been in place to coordinate and ensure the effectiveness of local work that safeguards and promotes the welfare of children.4 Section 11 of the Children Act sets out that each person or body to which it applies must take into account any guidance on the subject provided by the Secretary of State.

The staff training and continuing professional development requirements are described in Statutory guidance on making arrangements to safeguard and promote the welfare of children, which was published by the Government in August 2005.5

This guidance specifies that staff should understand 'their role and responsibilities, and those of other professionals and organizations', in order to ensure essential 'multi- and inter-agency collaboration.' It also encourages inter-agency as well as single agency training.6

The guidance specifies that PCTs should ensure that their own staff and those in services contracted by them:

  • are trained and competent to be alert to potential indicators of abuse or neglect in children6
  • know how to act on their concerns and fulfill their responsibilities in line with guidelines produced by the local Area Child Protection Committees (ACPC) or their successors – the LSCBs5
  • have undertaken child protection training, including refreshers to ensure that they are competent and aware of any changes5
  • are supported by a funded training strategy for child protection5
  • have a designated nurse and doctor who have over-arching responsibility across the PCT area (to include all providers).5

Standard 5 of the NSF for Children, Young People and Maternity Services relates to 'safeguarding and promoting the welfare of children and young people'.6 It sets out that 'all agencies (must) work to prevent children suffering harm and to promote their welfare, provide them with the services they require to address their identified needs and safeguard children who are being or who are likely to be harmed.'

In each individual practice, a child protection lead may be a helpful way of ensuring that all statutory and professional standards are met by the practice, although this is not a requirement.

In practical terms, the key areas of responsibility for each practice are that all staff:

  • are adequately trained
  • know the local procedures that are in place
  • know how to recognize when a child is at risk
  • know who to call for further advice or who to notify if a child may be at risk.

Management 2

The value of this indicator has been reduced from 1.5 points to 1 point.

The reduction in the points value of Management 2 was due to the belief that once the procedures have been put in place, no further work is required. Having procedures does not necessarily mean that they are adhered to, so it is worth checking that each component is met.

The new Directed Enhanced Service (DES) for information management and technology has four components.1 The fourth component of this DES rewards practices for moving to a 'connecting for health' accredited hosted system. A hosted server would result in the responsibility for computer back-up, verification of backup, storage, and loading programmes, being transferred to the organization that hosts the server, and no longer remaining with the practice.

Management 3

The value of this indicator has remained unchanged at 0.5 point.

Practices should remember to add details for new members of staff, and should not forget to include GP registrars.

Management 4

The value of this indicator has remained unchanged at 1 point.

In the past this has been easy to achieve because there were no national guidelines applicable to primary care.

However, the Healthcare Commission has confirmed the NHS's intention to implement the European Union Directive, 93/42/EEC in 2007.7,8 The Directive provides a European standard for medical devices, and includes details on the sterilization of surgical equipment. This will have a significant impact on the sterilization of surgical instruments in general practice.

The current methods of surgical instrument sterilization in general practice will not comply with the regulations. General practices will probably have to move to using single-use surgical instruments, unless they have access to a Central Sterile Services Department in a local hospital, which is able to supply the practice.1

Management 5

The value of this indicator has remained unchanged at 3 points.

PCTs have interpreted this indicator in different ways, particularly for single-handed practices. With the significant reorganization of PCTs in England, if small practices have agreed with their original PCT to a variation in opening times, it would be worth reconfirming this with the new PCT.

Management 6

The value of this indicator remains unchanged at 2 points.

It is worth looking back to ensure that a person specification and a detailed job description were available for the last few members of staff recruited. During practice visits, PCT staff are entitled to ask for this information for the last person employed by a practice. They have been known to seek confirmation from the employee that these documents were available at the time of appointment.

Management 7

The value of this indicator has remained unchanged at 3 points.

Again it is easy for these maintenance and calibration procedures to be forgotten in a busy practice. It can be valuable for this to be discussed at practice meetings, not only to ensure the work is carried out, but also to check that all staff understand the importance of it.

Management 8

The value of this indicator has remained unchanged at 1 point.

The importance of this indicator is not the monetary value of the QOF point, but the financial loss a practice might experience if appropriate safeguards are not put in place. Practices seem to believe that fraud could not happen to them, and they trust all their staff implicitly.

In the past year, I have either witnessed, or had experience of, the following:

  • a partner pre-signed all the practice cheques to allow the practice manager to provide the second signature without having to find a partner
  • a practice that was proud they had moved to internet banking, using a more secure method of staff payment each month. This required two people to provide unique passwords to authorize payment. The two passwords were kept on a single piece of paper in the practice manager's desk to allow any of the partners to authorize payment. Subsequently, £20 000 went 'missing' and was only detected by a very astute accountant
  • a practice where a single partner controlled all the finances and paid themselves twice what other partners were paid. None of the affected partners had seen the practice accounts for 5 years.

Most people are honest and trustworthy, but do not put temptation in their way. It is best to ensure practice management procedures are in place and understood by all.

Management 9

The value of this indicator has remained unchanged at 3 points.

Most social services departments are suffering from the same financial challenges as the rest of the NHS. Practices have reported that when carers are referred to social services, there are none available. A lack of funding is often cited as the reason for this lack of services.

Practices should have a protocol that includes:

  • a nominated lead in the practice, who is known to patients
  • contact information for local carers' help groups
  • a pack of carers' information (Focus on Carers and the NHS pack is available in some geographical areas).9

Without carers, significantly more patients would not only require additional NHS and social service resources, but would also have a much poorer quality of life. It is, therefore, important that carers are supported.

Management 10

The value of this indicator has gone down from 4 to 2 points.

If the practice has achieved this indicator in the past then the only work required for QOF2 is to review the procedure, and perhaps remind all practice staff of its existence. In some areas, practice managers have shared their written procedures manual, and other practices have modified their own procedures as a result.

Conclusion

There appears to be little change in the practice management domain of QOF2. The largest impact will probably be seen in the Management 4 indicator, if the expected national guidance on instrument sterilization is introduced. Policies and procedures should never be documents that are written to 'tick the box', but should be practice documents that are reviewed and updated regularly.

The QOF is funded annually and, therefore, it seems reasonable for practices to review their policies and procedures annually, otherwise it could be argued that they should no longer be funded under the QOF.

 

Guidelines in Practice, November 2006, Volume 9( 11 )
© 2006 MGP Ltd
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  1. British Medical Association. Revisions to the GMS contract 2006/07. Delivering Investment in General Practice. London: BMA, 2006.
  2. Presented to Parliament by the Secretary of State for Health and the Secretary of State for the Home Department. The Victoria Climbié Inquiry. Report of an Inquiry by Lord Laming, Norwich. Her Majesty's Stationery Office: London, 2003.
  3. Her Majesty's Stationery Office. Children Act 2004. London: Her Majesty's Stationery Office, 2004.
  4. Department for Education and Skills. Every Child Matters: Change for Children in the Criminal Justice System. London: Her Majesty's Stationery Office, 2004.
  5. Department for Education and Skills. Statutory guidance on making arrangements to safeguard and promote the welfare of children under section 11 of the Children Act 2004. London: Her Majesty's Stationery Office, 2005.
  6. Department of Health and Department for Education and Skills. Issues for Primary Care – National Service Framework for Children, Young People and Maternity Services. London: Department of Health, 2004.
  7. Medical Devices Directorate. Council Directive 93/42/EEC of 14th June 1993 concerning medical devices. Available from:
    http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31993L0042:EN:HTML
  8. http://deconprogramme.dh.gov.uk/default.aspx
  9. www.carers.org/data/files/carersnhs-11.pdf