Julian Le Saux
Julian has been working as a practice manager in Cranbrook, Kent, since 1990. It's a small surgery, and he still works in reception several mornings a week. In his spare time, Julian runs a website about primary care called Primary Care Info: www.primarycareinfo.org
Exception reporting has an important part to play in the new General Medical Services (GMS) contract. Those with reasonably long memories will recall that when the previous contract was introduced in 1990, it brought in targets for smears and immunisations. Many GPs were concerned that these targets would act as disincentives because they would be impossible to meet. In the event, the targeted system has delivered results in terms of national smear and immunisation uptakes, but patient compliance has always been better in some areas than others. There have certainly been occasions when conscientious GPs, through no fault of their own, have been unable to reach their targets and have ended up losing money.
The new contract ushered in a huge increase in targeted preventive care, but it also attempted to make the new targets more flexible than the old ones, through the introduction of an exception-reporting system. Practices were allowed to exception-report patients on the grounds of unsuitability or informed dissent, which meant that surgeries with patients who could not or would not come for checkups should be able to achieve the same points – and therefore the same earnings – as everyone else.
Unfortunately, the Quality and Outcomes Framework (QOF) system didn't come with sufficiently clear instructions as to how exception reporting should be used. When QOF came in, it was estimated that the average points score would probably be between 700 and 800 points. At the end of the first year, however, the average claim was for more than 1,000 points and, although this average undoubtedly reflected a great deal of hard work, there was an abundance of anecdotal evidence to suggest that it also reflected some clever manipulation of the exception-reporting system.
Muddying the waters
The new GP contract specifies that patients can be exception reported if they have been invited for checkups three times and have failed to respond. However, it doesn't specify how far apart those three invitations have to be spaced. If a patient is sent three invitations in the same week, for example, is exception reporting still justified? And what form do the invitations have to take? Do they all have to be in writing, or can they be verbal?
Flu invites are another grey area. Many of the chronic disease registers require their populations to come for flu jabs. But does an invitation for a flu jab count as one of the three invitations for the purposes of exception reporting? If an asthmatic patient has been invited for an asthma check once and a flu jab twice, and has failed to turn up for the flu jab, does that amount to "informed dissent", as the contract puts it?
In the end, the suspicion was that some practices were achieving maximum or near-maximum QOF points by finding ways to exception report any patients who posed a threat to their targets. As a result, primary care trusts (PCTs) have started to check up on practices with unusually high exception reporting figures.
The problem here, however, is that PCTs are looking at exception reporting figures on the Quality Management and Analysis System (QMAS) – the national IT system – which often differ quite widely from the figures of which the practice manager is aware. This can make it very difficult, if not impossible, to explain to the PCT exactly where the QMAS figures have come from.
Let's assume that you have 100 patients with diabetes on your list, and you know that on 31 March, 10 of these were exception reported as "unsuitable" and another 10 as "informed dissent". You might imagine that when you look at the QMAS exception summary report for diabetes, every row will have a denominator total of 80 (100 diabetics, minus the 20 who are exception reported), with 20 in the "Total Exceptions" column, 10 in the "Informed Dissent" column and 10 in the "Unsuitable" column. As a matter of fact, however, this is unlikely to be the case.
There is automatic exemption for any patients who have joined the practice within the last three months, or for those whose names have been added to the chronic disease register within the last three months. This means that the number shown in "Total Exceptions" may be higher than you were expecting, because some of your diabetic patients may be new to the practice or newly diagnosed. On the QMAS system, these patients will appear under either "Registration Date" or "Diagnosis Date" – and this will still happen even if you have exception reported them using a 9h code. So, although you may have marked 10 patients as "Informed Dissent" and 10 as "Unsuitable", if some of these patients are new they will be removed from the "Informed Dissent" and "Unsuitable" columns, and put in the "Registration Date" or "Diagnosis Date" columns instead.
Similarly, certain patients may be exempted from particular checks for special reasons. For example, patients coded as "never smoked" are exempted from having their smoking status checked every year; diabetic patients with a Read code of "Statin causing adverse effect in therapeutic use" or "Patient on maximal tolerated lipid-lowering therapy" are exempt from the requirement that their cholesterol should be <5, and so forth. On QMAS, exemptions of this type appear in the "Other" column of the exception summary report; and again, they will be listed under "Other" even if you have exception-reported them using a 9h code, which may throw your figures out.
Even more confusingly, patients who have been exception reported or exempted do not count against the practice for any of the clinical indicators in a given chronic disease register, but they do count in the practice's favour if they comply with any of the clinical indicators. This means that QMAS takes them out of whichever exception reporting column they were in, and adds them back into the denominator total.
If you have 20 patients on your diabetes register of 100 who have been exception reported using a 9h code, and they all come in for their blood pressure checks, none of them will show up in any of the exception reporting columns on the DM11 row on QMAS. A practice manager would probably look at this and think, "Hold on – I know I've exception reported 10 of these patients – why aren't they showing?"
Or, if three of the exception reported patients came and had their blood pressure taken, but the other seven didn't, the denominator total for DM11 would be 93 – the whole register, minus the exception reported 10, plus the exception reported three who turned up and were therefore added back in. In this case, the practice manager would probably think, "Hold on – I've got 10 exception reported patients – why is the system only showing seven?"
For all these reasons, it may be difficult to explain to the PCT, line-by-line, why the exception summary report is showing the figures it does. Even if you did explain it to them, they might not understand, because they are just as confused by the QMAS system as the rest of us.
There are lessons here for both practice managers and PCTs. Practice managers need to be aware that there is more to exception reporting than the use of 9h codes. They need to be aware of codes like the one for statin intolerance, because if PCTs notice that these codes are being used with above-average frequency, then they may call on the practice manager to provide patient-by-patient justification.
For their part, PCTs need to accept that if they ask practice managers to justify every figure on the entire exception summary report, they will be setting an almost impossible task. The way to control the improper use of exception reporting is to establish clear protocols and treat the issue as a matter of clinical governance. Attempting to decipher the hidden meanings of the figures on QMAS is only going to cause headaches all round.