Table 2 Indicators piloted and examples of issues raised as a result of piloting

1

Asthma

The percentage of patients with asthma who have had an asthma review in the previous 15 months that includes an assessment of asthma control using the 3 Royal College of Physicians questions (control of daytime, night time and activity limiting symptoms in the last week.

• Technical feasibility: need for revised IT data entry templates

Acceptability: no barriers

• Administration of questions by phone, post or face to face

Feasibility: some barriers

Reliability: some barriers

Implementation: no barriers

Overall: some barriers to address

2

Dementia

The percentage of patients with a new diagnosis of dementia to have FBC, calcium, glucose, renal and liver function, thyroid function tests, serum vitamin B12 and folate levels recorded 6 months before or after entering on to the register

• Inconsistency with dementia referral pathways/referral governance

Acceptability: no barriers

• Variation in practice - QOF danger of standardizing practice

Feasibility: no barriers

• Low prevalence in some practices (as confirmed by the pilot)

Reliability: no barriers

• Tests of calcium levels not always routinely done

Implementation: some barriers

Overall: some barriers to address but can go forward

3

Diabetes

The percentage of patients with diabetes with a record of testing of foot sensation using a 10 g monofilament or vibration (using biothesiometer or calibrated tuning fork), within the preceding 15 months

• Changes required to data entry diabetes templates where not already included

Acceptability: no barriers

• Education or training of nurses in some practices.

Feasibility: no barriers

Reliability: no barriers

Implementation: no barriers

Overall: no barriers

4

Diabetes

The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) or 4) ulcerated foot within the preceding 15 months

• Changes required to data entry diabetes templates where not already included

Acceptability: no barriers

• Education or training of nurses in some practices.

Feasibility: no barriers

• Routine data recording

Reliability: no barriers

• Workload implications for practice staff

Implementation: some barriers

• Attribution problems in terms of payments attached to QOF if performed outside the practice

Overall: some barriers to address but can go forward

• Time taken to perform

5

Myocardial Infarction

The percentage of patients with a history of myocardial infarction (from 1 April 2011 {from 1 October 2009 for the purposes of piloting} currently treated with an ACE inhibitor, aspirin or an alternative anti-platelet therapy, beta-blocker and statin (unless a contraindication or side effects are recorded)

Implementation issues:

Acceptability: some barriers

• Problems of attribution/hospital led prescribing

Feasibility: no barriers

• PCT formulas/guidance/pharmacy advisors content and advice is contrary to NICE guidelines

Reliability: no barriers

MI was the only area for which there is useable cost-effectiveness data

Implementation: some barriers

Overall: some barriers to address but can go forward

6

Myocardial Infarction

The percentage of patients with a history of myocardial infarction who have a record of intolerance or allergy to an ACE inhibitor who are currently treated with an ARB (unless a contraindication or side effects are recorded)

• Conflicts with variations in local guidance (in some areas PCT stipulates trying 3 ACEs before an ARB, in others ARB is front line treatment)

Acceptability: some barriers

• Variation in percentage of patients on ARB

Feasibility: no barriers

• Problems of attribution/hospital led prescribing

Reliability: no barriers

• Variations in local procedures in i.e. PCT formulas/guidance/pharmacy advisors

Implementation: some barriers

• Private initiated prescribing effects % of patients on ARB

Overall: some barriers to address but can go forward

MI is the only area for which there is useable cost-effectiveness data

7

Serious Mental Illness

The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 15 months

• Seldom heard group, whom often consult opportunistically. Difficulty getting patients to come back in

Acceptability: some barriers

Feasibility: no barriers

Reliability: no barriers

Implementation: some barriers

8

Serious Mental Illness

The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 15 months

• Low levels of cervical screening

Overall: some barriers to address but can go forward

9

Serious Mental Illness

The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 15 months

• Perceived clinical irrelevance to younger patients re. annual cholesterol, BP, HBA1c/glucose check: these are not routinely done in all practices for all patients on the current register

10

Serious Mental Illness

The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol: hdl ratio level in the preceding 15 months

• May create undue focus on individual processes/indicators in unbundled indicators rather than the overall physical health of patient "appropriate to their age, gender and health status"

11

Serious Mental Illness

The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose level or HBA1c in the preceding 15 months

12

Serious Mental Illness

The percentage of women aged 25-64 with schizophrenia, bipolar affective disorder and other psychoses who have a record of cervical screening within the last 5 years

13

Palliative Care

The percentage of patients on the palliative care register who have a preferred place to receive end-of-life care documented in the records

• Perceived potential harm to patients

Acceptability: preclude

• Changes to timing of which patients are put on the register: the palliative care register is perceived to often be quite subjective

Feasibility: no barriers

• The indicator does not pro-actively encourage GPs to keep the preferred place for end of care up to date

Reliability: no barriers

• Anxiety over the rigidity of the stipulated timeframes which are too prescriptive

Implementation: preclude

• Undue focus on one isolated question from a mutlifaceted and complex issue

Overall: preclude

• Problems of attribution/not necessarily general practice team's responsibility