On 1 April 2004 the majority of UK practices signed contracts, for three years in the first instance, with their local primary care organisations (PCOs). These contracts represent the largest upheaval in the NHS since its inception. They will mean a considerable shift in activities for family doctors working in practices, which are now responsible for care, as opposed to the individual doctors themselves. The contract is designed to deliver uniform primary diabetes care throughout the NHS.
GPs’ income will now be determined by a variety of measures, including:
- a global sum that forms at least half of the income for the practice
- payment for providing specifically determined patient services for the primary care organisation (PCO)
- seniority payments
- Quality and Outcomes (Q&O) payments for achieving a number of clinical and organisational goals.
Approximately one third of GPs’ income will be generated from Q&O payments. Of the 550 points awarded for achieving clinical quality indicators, 99 are for diabetes care (18% of the total). Table 1 lists the quality indicators for diabetes. The clinical indicators are divided into three different types: structure, process and outcome.
To fulfil these quality criteria for diabetes, practices must have systems in place to address them. The contract is about not only doing the work, but also demonstrating that it has been done. Since data are best recorded electronically, paper-light or paper-free practices will have the advantage over those that are not. In response to this, there has already been a rapid expansion in resources for IT within primary care trusts (PCTs).
Disease and therapy registers, and the ability to enter, and search for, clinical data will be essential to achieving the clinical indicators. Read codes specified by the contract are very important (Table 2). Read codes are searchable by the practice, and externally verifiable by the PCT to confirm claims. All the codes for the new contract are on the BMA website at: www.bma.org.uk/ap.nsf/Content/ newreadcodes. The diabetes codes and exception codes are at www.equip.ac.uk/ docs/readcodes/read_codes.pdf.
Many practices are appointing data managers, with protected time for data entry and audit, to improve the quality of practice data. Up to 40% of patients with diabetes may be attending hospital clinics, and it is important that the data from these clinics are assimilated into GP clinical systems.
The first requirement is a disease register of patients with diabetes aged 17 years and over. Many practices will have been developing these over the years as part of chronic disease management, and may want to verify lists by searching under diabetes therapy. They will need to demonstrate to the PCO how the register is formed, verified and maintained. Practices should expect 2–3% of their population to have diabetes, although variations in prevalence can be adjusted for, as illustrated later in this article.
In practice most of the recording of diabetes data will work on a 15-month cycle, with practices trying to achieve one-year follow-ups. The most difficult patients to reach are adolescents, who are poor clinic attendees, the housebound elderly, and those in nursing homes.
Body mass index (BMI)
There is a requirement for a percentage of the population to have had their BMI recorded within the past 15 months. Obesity is strongly associated with type 2 diabetes, and weight loss can help with diabetes control. Unfortunately, weight loss is often hard to achieve in people with diabetes, and many diabetes therapies, with the exception of metformin, tend to cause weight gain.
Recording of smoking status is found in several of the quality indicators, and one coded recording of the status covers all. In diabetes, smoking leads to a four-fold increase in risk of death. The first of the two indicators relates to the percentage of diabetes patients with a record of smoking status. Lifelong non-smokers need only have a single computer entry, but smokers and ex-smokers must have their entry updated within the 15-month cycle. For smokers, the percentage offered smoking cessation advice or intervention should be recorded on the practice computer system.
Blood glucose markers
There are no points for merely measuring blood sugar – it is important to record HbA1c for all patients with diabetes. Ideally, the test should be performed every 6 months in well-controlled patients and more often in patients with suboptimal control. Care should be taken to record accurately onto templates. There is a Read code for ‘HbA1c taken’, but the actual level may need to be recorded and searched for in a different way, depending on individual systems.
The contract divides patients with diabetes into those with HbA1c <7.4%, which equates with tight control in outcome studies, and those with HbA1c 10% or lower. Diabetes Mellitus (DM) 6 and 7 respectively reflect the difficulty in achieving these standards.
The upper band of control recognises findings from the UKPDS trial (UKPDS, 1998a). As glycaemic control worsens over time, more treatment is needed, but even with insulin therapy this may be difficult to achieve. It has to be accepted that some patients find it difficult to make the lifestyle choices necessary for good control. This is partially recognised in the contract, which allows for exception reporting in defined circumstances (Table 3).
A national retinal screening programme is being introduced, with regional differences. Suggested ways of implementing the programme have been a mix of screening locally in individual practices, by optometrists and at hospitals. This was a key suggestion in many of the diabetes frameworks. It will be important for practices locally to use services that are appropriate for them, and to capture data wherever they are recorded, as the top clinical indicator level for this activity is 90%.
Foot pulses and neuropathy
It is widely accepted that recording of foot pulses and neuropathy testing are important parts of an annual diabetes examination. Practices are beginning to assess neuropathy through consistent 10g pressure with a light touch monofilament. Foot pulses also require careful palpation. There are Read codes for all these data. Practices will need to cooperate locally with community podiatrists.
Like good glycaemic control, good blood pressure control is important but difficult to achieve, with patients with diabetes requiring several antihypertensive agents. In the UKPDS trial, controlling blood pressure was shown to be more effective in improving cardiovascular outcomes than maintaining tight blood glucose control (UKPDS, 1998b). In the new contract, the target blood pressure in people with diabetes is ≤145/85mmHg, compared with ≤159/90mmHg in those without diabetes.
This clinical indicator offers maximum points for recording blood pressure in 90% of patients with diabetes. Points for the percentage of patients with blood pressure ≤145/85mmHg will be harder to achieve, yet at 17 points will be important and worthwhile.
Diabetic renal disease
The three indicators associated with renal disease reflect screening for and management of diabetic renal disease. Both microalbuminuria and established proteinuria are markers for end-stage renal failure in type 1 diabetes, and predictive of imminent vascular disease in type 2 diabetes.&
There is good evidence that treatment with angiotensin-converting enzyme (ACE) inhibitor and angiotensin II (A2) antagonist may be reno-protective. Once microalbuminuria is established by two abnormal albumin:creatinine ratios, treatment with either ACE inhibitor or A2 antagonist should be given.
The new contract also rewards the recording of serum creatinine. This test is helpful in patients with diabetes who have established nephropathy, to detect non-diabetic renal disease, in those on ACE inhibitors, and to ensure the safe use of oral hypoglycaemics.
The lipid indicators reflect the widely held view that treating patients with diabetes to the same standard as those who need secondary prevention of cardiovascular disease is cost-effective. Major studies of primary and secondary prevention of cardiovascular disease using statins show benefit in diabetes subgroup analysis.
In the contract, points are offered for recording total cholesterol and achieving levels below 5mmol/litre, with maximum payment for 60% of patients with diabetes achieving this target. Commentators have observed that serum cholesterol alone is a crude observation in patients with diabetes, who have a subtle and complex lipid profile. There is debate as to whether all patients with diabetes over a certain age should receive lipid-lowering therapy and aspirin irrespective of risk table analysis. This is not reflected in the current contract, but may evolve with time.
All patients with diabetes should be offered influenza vaccination. This makes sense but is a small reward for the considerable effort required, with the maximum percentage set at 85% and only 3 points awarded for this.
When these and other aspects of the Q&O framework were published, practices had time to consider their aspirations within this framework. They then informed PCOs of their intended target aspirations and, as part of the new GMS contract, are receiving funding for these aspirations. These payments are coming to practices in monthly increments of one-third of the total aspiration points.
Table 1 shows that there are maximum thresholds that allow practices to claim payments, e.g. only 50% of patients need to achieve the HbA1c threshold of 7.4%. Observers have noticed that a few patients may make a large difference to these thresholds, and this is important when considering exception reporting.
Those involved with primary diabetes care will recognise that, in order to achieve many of the targets in diabetes, practitioners working in primary care need to enter into a concordant relationship with the patient with diabetes and there needs to be general agreement on mutual outcomes. With exception reporting, GPs have – for the first time – a facility to detail patients with diabetes who cannot, will not, or should not have a particular intervention.
The new GMS contract allows GPs to exclude individual patients from the disease indicators in certain circumstances (Table 3). In most cases, it is necessary to add a particular Read code to except a patient. Excepting can be done at two levels:
- removing a patient from one specific disease area
- removing a patient from a denominator of the whole disease area.
For valid exception coding to be achieved, these issues will have to be fully discussed with individual patients and carefully documented. Many practices that run specific diabetes clinics are recording their invitations to patients to attend these, noting refusals, and exempting patients after three non-attendances. However, if a patient is given a general exception code, they can still earn points for the practice if data around their condition are recorded. Table 4 gives examples of how this will work in practice.
Observers may feel that exception coding could be used too liberally by practices. An individual practice’s activity in the area of diabetes care and the other clinical indicators will be assessed by the Quality Management and Analysis System (QMAS). This is a national data collection and software analysis tool, which will be rolled out to practices, initially in England, and should allow them to compare their performances with those of others in their PCO and with national averages. The QMAS will work in tandem with, and inform, the PCT’s annual Q&O framework review, which should be conducted by a clinical team that includes a GP.
Having carefully examined the criteria for exception reporting and decided on denominator numbers for patients with diabetes, the practice now has to perform another complex calculation to decide potential income from diabetes work. A full explanation of the calculations can be found in the GMS Statement of Financial Entitlements for 2004/5 (2004).
The contract negotiators recognised that practices with a high number of patients with diabetes need to have their workload recognised financially. This is important in diabetes where there are pockets of high prevalence within localities with high ethnic populations who are susceptible to diabetes. At the same time they wanted to encourage practices with small numbers to participate in the process.
From 14 February 2005 onwards – this date will recur annually as National Prevalence Day – the prevalence of each of the diseases in the Q&O framework will be decided, partially informed by data from the QMAS. It appears that a prevalence figure will be agreed for each of the four countries within the NHS.
It is against this background that the Adjusted Disease Factor (ADF) calculations for diabetes are made. The practice (contractor) begins by calculating a Raw Practice Disease Prevalence by dividing the number of patients on the diabetes register by the Contractor Registered Population (CRP), which is agreed quarterly. (A formula is applied if the practice falls below the bottom 5% cut-off range.) Table 5 shows the calculation.
Table 6 illustrates how it will affect three practices. These separate practices show that the formula only partially recognises high prevalence. Practices with a particularly high prevalence will find that the formula only partially compensates them for their extra work, as the square root used in the formula tends to bring the ADF closer to one. Practices that looked at the headline figures in the contract without looking at their individual circumstances may be surprised when formulae are applied to their data next March.
The principle of rewarding practices for applying evidence-based interventions underpins the new GMS contact. Many of the diabetes interventions are justified by well-respected evidence. This is already having an impact on clinical practice, with practices informing PCOs of their intentions, and aspiration money is following these suggestions.
Practices will need to be aware of the implications of exception reporting people with diabetes in whom it is not appropriate to pursue targets.
Finally, practices will want to clarify how their individual circumstances in the context of disease prevalence and practice size will affect their remuneration from diabetes-related work.
*The four national diabetes frameworks are:
- National Service Framework for Diabetes: Standards (2001); Delivery Strategy (2003) http://www.publications. doh.gov.uk/nsf/diabetes/index.htm (accessed 21.09.04)
- National Service Framework for Diabetes (Wales) (2003) http://www.wales.nhs.uk/sites/documents/334/diabetes- standards-wales.pdf (accessed 21.09.04)
- Northern Ireland Diabetes Framework (2003) http://www. diabetes.org.uk/n.ireland/nireland.htm (accessed 21.09.04)
- Scottish Diabetes Framework (2002) http://www.diabetes. org. uk/scotland/downloads/sdf.pdf (accessed 21.09.04)