The medical journals are currently, predictably, full of ‘how to get your points’ features in the months that herald the arrival of the new GMS contract and its Quality and Outcomes Framework. If you haven’t realised by now, there are 99 points up for grabs for diabetes management, and around the country practices sit huddled over computer printouts and cold coffee, trying to figure out their predicted prize money.
But there is one aspect of the new framework which has gone largely unnoticed, yet it is one which will throw a lifeline to many practices – exception reporting.
Recognising that patients (and doctors) often fail to do what they should, the system allows for certain exceptions which will not feature in the data collection. The exceptions include:
- Patients who repeatedly fail to attend their review.
- Patients for whom it is not appropriate to review the chronic disease parameters, such as the terminally ill or the frail.
- People who are newly diagnosed or newly registered (as there will have been insufficient time to collect all of the necessary data).
- Patients who are taking the maximum tolerated doses of medication whose levels remain sub-optimal.
- Allergy or contraindication to prescribed medication.
- Intolerance to medication.
- Where the patient does not agree to investigation or treatment (informed dissent).
To make matters simpler, there will only be one or two READ codes for these exceptions, and you will not be expected to state why you have ‘exception reported’ individual cases (although it will be sensible to have made a note of this for when the points police call).
Practicalities
How will this work? Well, suppose you have 100 people with diabetes on your register. Figure 1 indicates a possible scenario.
FIGURE 1
- Five have failed to attend despite three documented requests.
- Two have a terminal illness.
- Miss Smith is 98 and has dementia.
- Nigel has needle phobia and refuses all blood tests.
- Three patients continue to have poor blood glucose control despite being on everything you can think of.
- Two patients have been diagnosed in the past month.
Suddenly, you are going to be assessed on 86 patients rather than 100. The targets begin to look much more reachable. For glycaemic control in particular, which attracts 30 of the 99 points, most practices should at least be able to collect 11 points for the target level of HbA1c of 10%, as most patients above this level will be on maximum tolerated doses of medication.
Problems
Of course the system is open to abuse. What constitutes ‘frail’? Who defines ‘maximum tolerated’? What is important is that the total number of patients on the register remains accurate before the exceptions, otherwise the data will show a falsely low prevalence of diabetes, giving the government an excuse to reduce investment or to claim that their health policies have brought about a dramatic reduction in the condition (some hope!).
Must go, a cup of cold coffee awaits, and I feel a little frail…
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