All practices should record the ethnicity of new patients, and keep up-to-date clinical summaries in patient records, as Dr Nigel Watson explains


   

The Records and Information domain of QOF2 has been changed significantly from its original format in QOF1.1A total of 14 indicators have been withdrawn, and three new indicators have been introduced.

Summary of changes

The following indicators have been withdrawn: Records 1, 2, 4, 5, 6, 7, 10, 12 and 14; and Information 1, 2 and 6. New indicators include:

  • Records 20 – the practice has up-to-date clinical summaries in at least 70% of patient records
  • Records 21 – ethnic origin is recorded for 100% of new registrations
  • Records 22 – the percentage of patients aged over 15 years whose notes record smoking status in the past 27 months, except those who have never smoked where smoking status need be recorded only once.

For this organizational domain, 24.5 points have been withdrawn and 24 new points have been added; making the total number of points available 92.5 (Table 1).

Table 1: Records and information Indicators in QOF2
Indicator no
Clinical indicator
Points
RECORDS 3
The practice has a system for transferring and acting on information about patients seen by other doctors out of hours
1
RECORDS 8
There is a designated place for the recording of drug allergies and adverse reactions in the notes, and these are clearly recorded
1
RECORDS 9
For repeat medicines, an indication for the drug can be identified in the records (for drugs added to the repeat prescription with effect from 1 April 2004). Minimum Standard 80%
4
RECORDS 11
The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 65% of patients
10
RECORDS 13
There is a system to alert the out-of-hours service or duty doctor to patients dying at home
2
RECORDS 15
The practice has up-to-date clinical summaries in at least 60% of patient records
25
RECORDS 17
The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 80% of patients
5
RECORDS 18
The practice has up-to-date clinical summaries in at least 80% of patient records
8
RECORDS 19
80% of newly registered patients have had their notes summarized within 8 weeks of receipt by the practice
7
RECORDS 20
The practice has up-to-date clinical summaries in at least 70% of patient records
12
RECORDS 21
Ethnic origin is recorded for 100% of new registrations
1
RECORDS 22
% patients aged over 15 years whose notes record smoking status in the past 27 months, except those who have never smoked where smoking status need be recorded only once (payment stages 40%-90%)
11
INFORMATION 3
The practice has arrangements for patients to speak to GPs and nurses on the telephone during the working day
1
INFORMATION 4
If a patient is removed from a practice's list, the practice provides an explanation of the reasons in writing to the patient and information on how to find a new practice, unless it is perceived that such an action would result in a violent response by the patient
1
INFORMATION 5
The practice supports smokers in stopping smoking by a strategy that includes providing literature and offering appropriate therapy
2
INFORMATION 7
Patients are able to access a receptionist via telephone and face to face in the practice, for at least 45 hours a day over 5 days, Monday to Friday, except where agreed with the PCO
1.5

Why the changes were made

When this section of the QOF was being negotiated, it was intended to reward good practice and incentivize GPs to improve their clinical records. For QOF2, the review team decided that some of the quality markers could be combined together to establish a more meaningful indicator, while others no longer required ongoing work and should, therefore, be withdrawn.

It is a basic GMC requirement that all consultations with patients should be recorded, and that this record should be legible.2 This not only means recording a history, relevant examinations, and medication, but also a management plan where appropriate. As most practices are now using electronic clinical records, legibility should not be an issue.

A practice cannot provide a safe clinical environment if it does not have a system in place to enable clinicians to access information at the appropriate time.To store clinical information in date order is an important issue if the practice is using written patient records, but is done automatically when electronic records are used.

The Records indicators 1, 2, 4, 5, 6, 7, 12 and 14 were removed because it was decided that payment for 2 years had enabled practices to reach these standards, which are the minimum all practices should be achieving. There is little ongoing work required once these standards have been met. All these indictors have largely been replaced by Records 20, which requires practices to have up-to-date clinical summaries in at least 70% of patient records.

Records indicators 10 and 16 both referred to recording smoking status in patients aged between 15 and 75 years, giving targets of 55% and 75%, respectively. This has established baseline smoking data in most practices. Changes to the QOF mean that these two indicators merge into one, Records 22, for all patients aged over 15 years. Non-smokers only require this to be noted once, but current smokers need to have their status reviewed every 2 years (indicator looks at the past 27 months, i.e. 2 years plus 3 months leeway).

All practices have well established mechanisms for contacting the out-of-hours service and hence Information indicators 2 and 8 have been withdrawn.

Ethnicity

The only completely new area in QOF2 is that all people who register with a new practice should be asked for their ethnic origin. As this indicator is only worth 1 point (or £124.60 to the average practice of 5891 patients), some practices may decide that it is not worth pursuing. There are a number of Read codes which are available (Table 2).

Table 2: Read codes for ethnicity
White
9S1
Black African
9S2
Black Caribbean
9S3
Indian
9S6
Pakistani
9S7
Chinese
9S9
Decline to state
9SD

Conclusion

This organizational domain has significantly changed in terms of the specific indicators, with little change in the funding available and the overall work required. The recording of ethnicity would appear to have more to do with the Government's drive to record this information, than the immediate clinical benefit.

If ethnicity was recorded in all patients' electronic health records, there could be significant gains when looking at public health issues, for example, specific ethnic variation of certain diseases. It must not be forgotten that British general practice probably has the largest computerized database of clinical records in the world.3 The QOF has enhanced not only the quality and quantity of this information, but it has also made the information invaluable to those looking at the significant health issues in disease-specific areas.

 

Guidelines in Practice, September 2006, Volume 9(9)
© 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.gmc-uk.org/
  3. www.gprd.com/