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					     ANNUAL QUALITY AND OUTCOME FRAMEWORK
 REVIEW PROCESS AND PROCEDURE FOR BEDFORDSHIRE
               GENERAL PRACTICES

                                                2007/8




Authors:                Julie Wilkinson, Head of Clinical Governance
                        Jan Ferdinando, Clinical Governance Facilitator
                        Roxanna Mager, Clinical Governance Facilitator

Release date:           April 2007

Review Date:            April 2008

Approved by:            Bedfordshire PCT Strategic Commissioning Board

Approval date:          18 April 2007




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Contents

Contents .................................................................................................................... 2

1.    Background ........................................................................................................ 3

2.    Aims and Objectives ........................................................................................... 3

3.    Process .............................................................................................................. 4

4.    Random 5% Checks ........................................................................................... 4

5.    Pre Visit Analysis ................................................................................................ 4

6.    Practice QOF Visits ............................................................................................ 5

7.    Timetable............................................................................................................ 6

8.    Confidentiality and Consent ................................................................................ 7

9.    Pre-Payment Verification Checks ....................................................................... 7

10. Dispute Resolution ............................................................................................. 7

11. Quality Assurance .............................................................................................. 8

12. PCT Personnel ................................................................................................... 8

13. References ......................................................................................................... 9

Appendix 1 - Declaration ......................................................................................... 10

Appendix 2 QOF Domains ....................................................................................... 11

Appendix 3 – PCT Standards for Policies and Procedures ..................................... 28

Appendix 4 – QOF Process 07/08 Flow Chart ......................................................... 29

Appendix 5 – PCT Informal Dispute Resolution Flow Chart ..................................... 30

Appendix 6 Grade A evidence for submission by 31.3.08 for PPV ........................... 31

Appendix 7 LMC Local Dispute Resolution Procedure ........................................... 33




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1. Background
The Quality & Outcomes Framework is an integral part of the New Contract for General
Medical Services. It rewards Practices for delivering evidence-based care and is a
powerful tool in improving the quality of Primary Care. The PCT is responsible for
ensuring that payments are made appropriately.

The philosophy and methodology for measuring the Quality Outcomes Framework in
Bedford and Heartlands PCT‟s were different. It is essential that there is a consistent,
robust and fair approach in all Practices in Bedfordshire PCT from April 2007 to ensure
payments are verified and to assure the quality of care delivered. This paper describes
the process used to achieve this, which is based on the guidance in the Scharr Report 1.
In line with guidance issued by the Primary Care Contracting Team the QOF Process
aims to be “facilitative and positive whilst ensuring, through a careful, thorough and
thought through process at the PCT, that Practices are delivering QOF in the spirit of the
negotiated intentions so that patient care and experience continues to improve. Each
PCT must be able to satisfy the process of PCT internal audit” 2.

The Clinical Governance Team will use the quarterly GP Clinical Governance meetings
to facilitate discussions regarding the QOF. This collaborative work with the Practices
and the GP Assessors is an effective forum to provide clarification and guidance in order
to support Practices to achieve the QOF points and provide a fair measure where
clarification is required.

The Chief Executive of the Local Medical Committee has commented positively on this
process. The Strategic Commissioning Board approved it and it will be reported to the
Professional Executive Committee. It will be sent to all Bedfordshire Practices in April
2007.


2. Aims and Objectives
To establish a process whereby the PCT can support its Practices to meet the
Framework requirements and establish local „reasonable‟ measures where the
Framework lacks explicit detail or invites variable interpretation.

To implement a fair and systematic process of assessment and payment for all
Bedfordshire Practices.

To provide assurance to the Board that the quality of Chronic Disease Management in
General Practices locally meets Framework standards.

To comply with guidance from the East of England Strategic Health Authority‟s request to
ensure that Primary Care contracts are delivering the requirements and that payments
are justified with appropriate pre-payment verification, assessment visits and random
checks. Payments will be made in return for satisfactory evidence of quality attainment,
verified by the PCT by systematically reviewing rigorous data and lists provided by
Practices.



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3. Process
The relationship between the PCT and Practices in relation to the QOF is based on
mutual goals and understanding, with the values of patient interest and service
improvement at its heart.

The Beds PCT principle behind this QOF process is a standard approach for all Practices
with “earned autonomy” for those Practices who have demonstrated that they have
understood and embedded the Framework requirements to ensure that high quality care
is being delivered systematically.

At the beginning of the year Practices will be asked to sign a QOF Declaration stating
any indicators to which they are not aspiring and agreeing to submit the Grade A
evidence required by the PCT. This will include a statement that the Practice has read,
understood, and undertaken to meet the detail of the contract for any points claimed.

4. Random 5% Checks
The PCT will undertake a random check (usually in June/July) after payments have been
made in 5% of Practices (excluding those that have had a 5% check in the last 3 years or
a QOF Review Visit in this year). The check will look in detail at patient records to ensure
that the claims were appropriately made by the Practice and will necessitate a visit to the
Practice. If the claims are found to not match the Practice evidence for QOF indicators
claimed by the Practice, this may be discussed with the PCT Counter-Fraud Specialist for
further review.

The random selection will be made by the Chief Executive Officer drawing names from a
hat at a meeting of the Professional Executive Committee early in 2008. The Practices
will be notified just before the end of March if they have been selected, as they will be
required to run lists of patients on all disease registers as of the 31 March 2008. A PCT
Clinical Governance Manager and a GP Assessor will undertake the checks.

5. Pre-Visit Analysis
The use of Practice Profiles will provide an overall review of every Practice and guide the
PCT to areas requiring further discussion. The Profiles will be produced by the Business
Unit and will include QOF-related information, prescribing data and hospital activity
information.

Where a Practice Profile raises a query the Practice will be written to and asked to
respond. Where it is not possible to resolve a query through correspondence or where
there were concerns identified during last year‟s review a QOF Practice Visit will be
undertaken. QOF Review visits will not routinely be undertaken in all Practices but all
former Type 2 or new Practices will have a QOF Review Visit during their first year if they
are open for nine months or more by the 31 st March or in the following year. Any
Practices participating in the QOF for the first time will have a QOF Practice Visit.

The QOF Review Visits are costly in terms of Practice and PCT time but it has been
proven that, in some cases, they are required to assist Practices to ensure that the detail
of the Framework is met and that the PCT is making appropriate payments.


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The multidisciplinary QOF Review Panel will review each Practice‟s Profile to identify if
the data is consistent when triangulated with other relevant information or if it raises
further questions that require clarification or action.

The Panel will decide either that there are no concerns so a visit is not required, or
identify queries and ask the Practice to respond. Where the queries are not satisfactorily
resolved by 30 November 2007, a Practice QOF Review Visit will be arranged.

6. Practice QOF Visits
A PCT Manager (who is a member of the Clinical Governance Team and a member of
the QOF Profile Panel) will undertake the QOF Review Visits with a GP Assessor. The
purpose of the visit is to:
    Discuss the aspirations made in the Declaration by the Practice
    Discuss and verify any clinical issues arising from Practice Profiling in relation to
      clinical domains.
    Review outstanding quality issues not resolved last year.

A letter confirming the key issues and any actions required before the end of year will be
sent to the Practice after the visit.

If the Practice evidence seen at a QOF Review Visit does not meet the Framework
requirements, the Practice will be required to submit evidence before the 31 st March
2008. It is the Practice‟s responsibility to ensure these actions are completed to the
Framework standard.

If, during the Review visit, the Assessors encounter evidence of possible fraud the
Practice will be asked to provide further information. If these concerns remain
unresolved, the visit will be suspended. The PCT will ask for advice from the local
Counter-Fraud Specialist who may initiate an investigation.

In the unlikely event of the Assessors identifying any concerns in relation to poor clinical
performance these concerns will be discussed with the Practice during the visit. If the
concerns are not resolved, they will be referred to the PCT‟s Performance Committee for
further discussion. If the Performance Committee wishes to discuss these concerns
further with the Practice, the Practice may wish to ask an LMC representative to be
present.




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7. Timetable
Key Step                                                          PCT Timescale
PCT sends Declaration to Practices                                By 1 May 2007

Practices return completed Declaration including By 31 May 2007
Apollo QOF Assessor Reports

PCT Collate Practice Profiles                                     June – July 2007

PCT QOF Review Panel reviews profile, identifies
any queries and feeds back the outcome to the By 31 August 2007
Practice

Practice responds to queries where appropriate                    By 30 September 2007

PCT QOF Review Panel review Practices responses
and identify Practices requiring a visit        By end October 2007


Deadline for Practices to resolve Profile queries                 30 November 2007

QOF Practice Review visits                                        1 November 2007 – 31
                                                                  January 2008

Review follow up letter sent to the Practice                      Within 2 weeks after visit

Practice to submit evidence that all actions identified By 31 March 2008
at a Visit have been completed and submit all
required Grade evidence to the PCT to verify QMAS
claims.

Pre-Payment Verification Process                                  1 – 30 April 2008


Practices to be selected for 5% checks at meeting of
the Professional Executive Committee                 March 2008

5% Check Practice Visits                                          June-July 2008




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8. Confidentiality and Consent
To ensure that the QOF review process is robust access to patient records is essential,
particularly for issues regarding data quality, the pre-payment verification and random 5%
checks.

National Guidance published in The Department of Health paper “The Confidentiality and
Disclosure of Information: General Medical Services, Personal Medical Services and
Alternative Provider Medical Services Directions 2005 National Health Service Act 1977
24 March 2005” 3 states that for some purposes (and this includes the QOF Annual
Review Framework) the PCT may need to access and obtain information that identifies
individual patients.

The former Bedford PCT had agreement from the PCT‟s Caldicott Guardian and the
Local Medical Committee that only the GP Assessor will be able to review patient records
(as they are bound by the GMC or NMC Code of Conduct in relation to confidentiality).
This principle continues into the new process for Bedfordshire PCT.

9. Pre-Payment Verification Checks
After a Practice Visit, the Clinical Governance Facilitators will review any evidence
submitted by Practices on a monthly basis from Nov-Feb and the Practice will be notified
if it does not meet the Framework requirements.

After the Practices have submitted their claims and before the achievement payment is
made PCTs are required to conduct a Pre-Payment Verification (PPV) check on each
Practice in early April. The PCT will look at the Practice‟s QMAS achievement reports
and compare it with other practice data to confirm its validity.

The PCT will check that any previously identified actions have been completed and the
Practice has submitted evidence that meets the PCT request and the Framework
requirements. The Clinical Governance Team will liase with the Practice via the Practice
Manager and will not typically involve a visit to the Practice. However, where there are
significant outstanding concerns, this may involve a visit to the Practice by a GP
Assessor to review patients‟ records.

If, at the end of the financial year, the Practice is making claims that cannot be verified,
the PCT will liaise with the Practice to adjust the QMAS claims accordingly.


10.     Dispute Resolution
The PCT seeks to resolve all disputes at a local and informal level (Appendix 5). The
Quality Assurance Panel (see Section 12) will consider any local informal disputes at any
stage in the process. If the Practice does not wish to accept PCT changes to the end of
year QMAS declaration it should put this in writing to the Head of Clinical Governance
who will convene the Quality Assurance Panel who will review this dispute.

A contractor has the right of appeal against any PCT decisions made and may request
that it is resolved through a formal dispute resolution process. In the event of a formal
dispute the PCT has adopted the Bedfordshire and Hertfordshire Local Medical
Committee‟s Procedure. (Appendix 7).

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11.     Quality Assurance
Several mechanisms have been put in place to assure quality throughout the process.

       All Practices will go through a standard procedure where evidence and data are
        checked against pre-established criteria.

       The QOF Review Panel will make the decision with regard to the necessity and
        agenda for the QOF visit.

       The Quality Assurance Panel will review and approve the QOF Review Panel‟s
        decisions and the outcomes of all QOF Visits and any disputes.

       The PCT QOF Lead and the GP Assessor will sign the QOF Review Visit letters.

       Anonymous feedback from all Practices that have had a QOF Review Visit will be
        sought and a review of the process conducted at the end of the year.


12.     PCT Personnel
Director QOF Lead               Nicola Bell

Managerial QOF Lead             Head of Clinical Governance

QMAS Lead                       Clinical Governance Facilitator

QOF GP Assessors                To be recruited

QOF Review Panel                Head of Clinical Governance
                                Head of Primary Care Contracting
                                Head of Medicines Management
                                Clinical Networks Support Manager
                                Public Health Manager
                                Practice Nurses Development Manager
                                Clinical Governance Facilitators (2)
                                GP Assessor (s) – to be recruited

Quality Assurance Panel         Non- Executive Director (Chair)
                                Medical Director
                                Executive Nurse
                                Representative from Professional Executive Committee
                                Head of Clinical Governance
                                Head of Primary Care Contracting




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13.     References
    1 School Of Health and Related Research (SCHARR) University of Sheffield GMS
    Quality and Outcomes Framework; Annual Review Visits David Martin and Chris
    Fewtrel March 2004


    2 Primary Care Contracting Assessment Refreshed QOF Assessment - Statement of
    Purpose v2.0 2 December 2006


    3    The Confidentiality and Disclosure of Information: General Medical Services,
    Personal Medical Services and Alternative Provider Medical Services Directions 2005
    National Health Service Act 1977 24 March 2005




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Appendix 1 - Declaration

                     Practice Quality Outcome Framework Declaration
                                          2007/08
This Declaration states the Practice’s aspirations for achievement by the 31 March 2008.

The Practice is asked to sign and submit this Declaration with the QOF Apollo Assessor Reports
to the PCT by the 31 May 2007. Please note that failure to do so may result in the Practice
receiving a QOF Review Visit.

This information will be added to your Practice Profile that will be reviewed by the end of August
to identify any queries or necessity for a QOF Review Visit.

         Practice Name:

        Practice Address


We have read and are fully aware of the details required to claim payments for the
Framework indicators.

We will ensure that any points claimed meet the detailed requirements of the Framework.

We will review our disease prevalence to ensure that our disease registers are accurate
and complete.

We accept that the PCT may check our claims during routine QOF Review Visits, Pre-
Payments Verification Checks or the post-payment Random 5% Checks.

We are aspiring to all indicators                 Yes          No      
If you are not aspiring to all indicators, please list below the indicators that you will NOT
be completing:




Signed ………………………………………………………………. Practice GP QOF Lead


Name: ……………………………………………………………….. Date ……………………..


Signed ……………………………………………………………… Practice Manager


Name : ……………………………………………………………….. Date ………………………



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Appendix 2 QOF Domains

CLINICAL DOMAINS
Secondary Prevention of Coronary Heart Disease
Indicator      Description                                              Practice   Any    Practice
                                                                        Not        Comments
                                                                        Aspiring
CHD 1               The practice can produce a register of patients
4 points            with coronary heart disease.
CHD 2               The percentage of patients with newly
7 points            diagnosed angina (diagnosed after 1 April
                    2003) who are referred for exercise testing
                    and/or specialist assessment.
CHD5                The percentage of patients with coronary heart
7 points            disease whose notes have a record of blood
                    pressure in the previous 15 months.
CDH 6               The percentage of patients with coronary heart
19 points           disease in whom the last blood pressure
                    reading (measured in the previous 15 months)
                    is 150/90 or less.
CDH 7               The percentage of patients with coronary heart
7 points            disease whose notes have a record of total
                    cholesterol in the previous 15 months.
CHD 8               The percentage of patients with coronary heart
17 points           disease whose last measured total cholesterol
                    (measured in the previous 15 months) is
                    5mmol/l or less.
CHD 9               The percentage of patients with coronary heart
7 points            disease with a record in the previous 15
                    months that aspirin, an alternative anti-platelet
                    therapy, or an anti-coagulant is being taken
                    (unless a contraindication or side-effects are
                    recorded).
CHD 10              The percentage of patients with coronary heart
7 points            disease who are currently treated with a beta
                    blocker (unless a contraindication or side-
                    effects are recorded.
CHD 11              The percentage of patients with a history of
7 points            myocardial infarction (diagnosed after 1 April
                    2003) who are currently treated with an ACE
                    inhibitor or Angiotensin 11 antagonist.
CHD 12              The percentage of patients with coronary heart
7 points            disease who have a record of influenza
                    immunisation in the preceding 1 September to
                    31 March.




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Heart Failure

Indicator           Description                                        Practice   Any   Practice
                                                                       Not        Comments
                                                                       Aspiring
HF 1                The practice can produce a register of patients
4 points            with heart failure.
HF2                 The percentage of patients with a diagnosis of
6 points            heart failure (diagnosed after 1 April 2006)
                    which     has     been    confirmed   by    an
                    echocardiogram or by specialist assessment.
HF 3                The percentage of patients with a current
10 points           diagnosis of heart failure due to LVD who are
                    currently treated with an ACE inhibitor or
                    Angiotensin Receptor Blocker, who can
                    tolerate therapy and for whom there is no
                    contra-indication.

Stroke and TIA
Indicator      Description                                             Practice     Any Practice
                                                                       Not          Comments
                                                                       Aspiring
STROKE 1          Records
2 points          The practice can produce a register of patients
                  with Stroke or TIA.
STROKE 5          Ongoing Management
2 points          The percentage of patients with TIA or stroke
                  who have a record of blood pressure in the
                  notes in the preceding 15 months.
STROKE 6          The percentage of patients with a history of TIA
5 points          or stroke in whom the last blood pressure
                  reading (measured in the previous 15 months)
                  is 150/90 or less.
STROKE 7          The percentage of patients with TIA or stroke
2 points          who have a record of total cholesterol in the last
                  15 months.
STROKE 8          The percentage of patients with TIA or stroke
5 points          whose last measured total cholesterol
                  (measured in the previous 15 months) is
                  5mmol/1 or less.
STROKE 10         The percentage of patients with TIA or stroke
2 points          who have had influenza immunisation in the
                  preceding 1 September to 31 March.
STROKE 11         The percentage of new patients with a stroke
2 points          who have been referred for further investigation.
STROKE 12         The percentage of patients with a stroke shown
4 points          to be non-haemorrhagic, or a history of TIA,
                  who have a record that an anti-platelet agent
                  (aspirin, clopidogrel, dipyridamole or a
                  combination), or an anti-coagulant is being
                  taken (unless a contraindication or side-effects
                  are recorded).




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Hypertension

Indicator           Description                                       Practice Not Any Practice
                                                                      Aspiring     Comments
BP 1                Records
6 points            The practice can produce a register of patients
                    with established hypertension
BP 4                Ongoing Management
20 points           The percentage of patients with hypertension
                    in whom there is a record of the blood
                    pressure in the previous 9 months.
BP 5                The percentage of patients with hypertension
57 points           in whom the last blood pressure (measured in
                    the previous 9 months) is 150/90 or less.


Diabetes Mellitus

Indicator           Description                                       Practice Not Any Practice
                                                                      Aspiring     Comments
DM 2                Ongoing Management
3 points            The percentage of patients with diabetes
                    whose notes record DM1 in the previous 15
                    months.
DM 5                The percentage of diabetic patients who have
3 points            a record of HbA1c or equivalent in the previous
                    15 months.
DM 7                The percentage of patients with diabetes in
11 points           whom the last HbA1c is 10 or less (or
                    equivalent test/reference range depending on
                    local laboratory) in the previous 15 months.
DM 9                The percentage of patients with diabetes with
3 points            a record of the presence or absence of
                    peripheral pulses in the previous 15 months.
DM 10               The percentage of patients with diabetes with
3 points            a record of neuropathy testing in the previous
                    15 months.
DM 11               The percentage of patients with diabetes who
3 points            have a record of blood pressure in the
                    previous 15 months.
DM 12               The percentage of patients with diabetes in
18 points           whom the last blood pressure is 145/85 or
                    less.
DM 13               The percentage of patients with diabetes who
3 points            have a record of micro-albuminuria testing in
                    the previous 15 months (exception reporting
                    for patients with proteinuria).
DM 15               The percentage of patients with diabetes with
3 points            a diagnosis of proteinuria or micro-albuminuria
                    who are treated with ACE inhibitors (or A2
                    antagonists).

DM 16               The percentage of patients with diabetes who
3 points            have a record of total cholesterol in the
                    previous 15 months.
DM 17               The percentage of patients with diabetes

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Indicator           Description                                        Practice Not Any Practice
                                                                       Aspiring     Comments
6 points            whose last measured total cholesterol within
                    the previous 15 months is 5mmol/l or less.
DM 18               The percentage of patients with diabetes who
3 points            have had influenza immunisation in the
                    preceding 1 September to 31 March.
DM 19               Records
6 points            The practice can produce a register of all
                    patients aged 17 years and over with diabetes
                    mellitus, which specifies whether the patients
                    has Type 1 or Type 2 diabetes.
DM 20               The percentage of patients with diabetes in
17 points           whom the last HbA1c is 7.5 or less (or
                    equivalent test/reference range depending on
                    local laboratory) in the previous 15 months.
DM 21               The percentage of patients with diabetes who
5 points            have a record of retinal screening in the
                    previous 15 months.
DM 22               The percentage of patients with diabetes who
3 points            have a record of estimated glomerular filtration
                    rate (eGFR) or serum creatinine testing in the
                    previous 15 months.




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Chronic Obstructive Pulmonary Disease

Indicator        Description                                          Practice Not Any  Practice
                                                                      Aspiring     Comments
COPD 1           Records
3 points         The practice can produce a register of patients
                 with COPD.
COPD 9           Initial diagnosis
10 points        The percentage of all patients with COPD in
                 whom diagnosis has been confirmed by
                 spirometry including reversibility testing.
COPD 10          Ongoing management
7 points         The percentage of patients with COPD with a
                 record of FeV1 in the previous 15 months.

COPD 11          The percentage of patients with COPD receiving
7 points         inhaled treatment in whom there is a record that
                 inhaler technique has been checked in the
                 previous 15 months.
COPD 8           The percentage of patients with COPD who have
6 points         had influenza immunisation in the preceding 1
                 September to 31 March.


Epilepsy

Indicator           Description                                       Practice Not Any  Practice
                                                                      Aspiring     Comments
EPILEPSY 5          Records
1 point             The practice can produce a register of patients
                    aged 18 and over receiving drug treatment for
                    epilepsy.
EPILEPSY 6          Ongoing Management
4 points            The percentage of patients age 18 and over
                    on drug treatment for epilepsy who have a
                    record of seizure frequency in the previous 15
                    months.
EPILEPSY 7          The percentage of patients age 18 and over
4 points            on drug treatment for epilepsy who have a
                    record of medication review involving the
                    patient and/or carer in the previous 15 months.
EPILEPSY 8          The percentage of patients age 18 and over
6 points            on drug treatment for epilepsy who have been
                    seizure free for the last 12 months recorded in
                    the previous 15 months.

Hypothyroid

Indicator           Description                                   Practice Not Any  Practice
                                                                  Aspiring     Comments
THYROID 1           Records
1 point             The practice can produce a register of
                    patients with hypothyroidism.
THYROID 2           Ongoing Management
6 points            The percentage of patients with
                    hypothyroidism with thyroid function tests
                    recorded in the previous 15 months.

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Cancer

Indicator           Description                                   Practice Not Any  Practice
                                                                  Aspiring     Comments
CANCER 1            Records
5 points            The practice can produce a register of all
                    cancer patients defined as a „register of
                    patients with a diagnosis of cancer
                    excluding non-melanotic skin cancers‟
                    from 1 April 2003.
CANCER 3            Ongoing Management
6 points            The percentage of patients with cancer,
                    diagnosed within the last 18 months who
                    have a patient review recorded as
                    occurring within 6 months of the practice
                    receiving confirmation of the diagnosis.


Palliative Care

Indicator           Description                                   Practice Not Any  Practice
                                                                  Aspiring     Comments
PC 1                Records
3 points            The practice has a complete register
                    available of all patients in need of
                    palliative care/support.
PC 2                Ongoing Management
3 points            The practice has regular (at least 3-
                    monthly) multidisciplinary case review
                    meetings where all patients on the
                    palliative care register are discussed.




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Mental Health

Indicator           Description                                       Practice Not Any  Practice
                                                                      Aspiring     Comments
MH 4                The percentage of patients on lithium therapy
1 point             with a record of serum creatinine and TSH in
                    the preceding 15 months.
MH 5                The percentage of patients on lithium therapy
2 points            with a record of lithium levels in the
                    therapeutic range within the previous 6
                    months.
MH 6                The percentage of patients on the register who
6 points            have a comprehensive care plan documented
                    in the records agreed between individuals,
                    their family and/or carers as appropriate.
MH 7                The percentage of patients with schizophrenia,
3 points            bipolar affective disorder and other psychoses
                    who do not attend the practice for their annual
                    review who are identified and followed up by
                    the practice team within 14 days of non-
                    attendance.
MH 8                Records
4 points            The practice can produce a register of people
                    with schizophrenia, bipolar disorder and other
                    psychoses.
MH 9                Ongoing Management
23 points           The percentage of patients with schizophrenia,
                    bipolar affective disorder and other psychoses
                    with a review recorded in the preceding 15
                    months.      In the review there should be
                    evidence that the patient has been offered
                    routine health promotion and prevention
                    advice appropriate to their age, gender and
                    health status.




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Asthma

Indicator           Description                                    Practice Not Any  Practice
                                                                   Aspiring     Comments
ASTHMA 1            Records
4 points            The practice can produce a register of
                    patients with asthma, excluding patients
                    with asthma who have been prescribed no
                    asthma-related drugs in the previous
                    twelve months.
ASTHMA 3            Ongoing Management
6 points            The percentage of patients with asthma
                    between the ages of 14 and 19 in whom
                    there is a record of smoking status in the
                    previous 15 months.
ASTHMA 6            The percentage of patients with asthma
20 points           who have had an asthma review in the
                    previous 15 months.
ASTHMA 8            Initial Management
15 points           The percentage of patients aged eight and
                    over diagnosed as having asthma from 1
                    April 2006 with measures of variability or
                    reversibility.


Dementia

Indicator           Description                                   Practice Not Any  Practice
                                                                  Aspiring     Comments
DEM 1               Records
5 points            The practice can produce a register of
                    patients diagnosed with dementia.
DEM 2               Ongoing Management
15 points           The percentage of patients diagnosed
                    with dementia whose care has been
                    reviewed in the previous 15 months.




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Depression

Indicator           Description                                    Practice Not Any  Practice
                                                                   Aspiring     Comments
DEP1                Diagnosis and initial management
8 points            The percentage of patients on the diabetes
                    register and/or the CHD register for whom
                    case finding for depression has been
                    undertaken on one occasion during the
                    previous 15 months using two standard
                    screening questions.
DEP 2               In those patients with a new diagnosis of
25 points           depression, recorded between the preceding
                    1 April to 31 March, the percentage of
                    patients who have had an assessment of
                    severity at the outset of treatment using an
                    assessment tool validated for use in primary
                    care.


Chronic Kidney Disease

Indicator           Description                                    Practice Not Any  Practice
                                                                   Aspiring     Comments
CKD 1               Records
6 points            The practice can produce a register of
                    patients aged 18 years and over with CKD
                    (US National Kidney Foundation: Stage 3 to
                    5 CKD).
CKD 2               Initial Management
6 points            The percentage of patients on the CKD
                    register whose Comments have a record of
                    blood pressure in the previous 15 months.
CKD 3               Ongoing Management
11 points           The percentage of patients on the CKD
                    register in whom the last blood pressure
                    reading, measured in the previous 15
                    months, is 140/85 or less.
CKD 4               The percentage of patients on the CKD
4 points            register with hypertension who are treated
                    with an angiotensin converting enzyme
                    inhibitor (ACE-1) or angiotensin receptor
                    blocker (ARB) (unless a contraindication or
                    side effects are recorded).




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Atrial Fibrillation

Indicator             Description                                         Practice Not Any  Practice
                                                                          Aspiring     Comments
AF1                   Records
5 points              The practice can produce a register of
                      patients with atrial fibrillation.
AF 2                  Initial Diagnosis
10 points             The percentage of patients with atrial
                      fibrillation diagnosed after 1 April 2006 with
                      ECG or specialist confirmed diagnosis.
AF 3                  Ongoing Management
15 points             The percentage of patients with atrial
                      fibrillation who are currently treated with anti-
                      coagulation drug therapy or an anti-platelet
                      therapy.


Obesity

Indicator             Description                                         Practice Not Any  Practice
                                                                          Aspiring     Comments
OB 1                  Records
8 points              The practice can produce a register of
                      patients aged 16 and over with a BMI
                      greater than or equal to 30 in the previous
                      15 months.

Learning Disabilities

Indicator             Description                                         Practice Not Any  Practice
                                                                          Aspiring     Comments
LD 1                  Records
4 points              The practice can produce a register of
                      patients with learning disabilities.

Smoking

Indicator             Description                                         Practice   Not Any Practice
                                                                          Aspiring       Comments
Smoking 1             The percentage of patients with any or any
33 points             combination of the following conditions:
                      coronary heart disease, stroke or TIA,
                      hypertension, diabetes, COPD or asthma
                      whose notes record smoking status in the
                      previous 15 months. Except those who have
                      never smoked where smoking status need
                      only be recorded once since diagnosis.
Smoking 2             The percentage of patients with any or any
35 points             combination of the following conditions:
                      coronary heart disease, stroke or TIA,
                      hypertension, diabetes, COPD or asthma
                      who smoke whose notes contain a record
                      that smoking cessation advice or referral to a
                      specialist service, where available, has been
                      offered within the previous 15 months.


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ORGANISATIONAL DOMAIN

Records and Information

Indicator           Description                                        Practice Not Any Practice
                                                                       Aspiring     Comments
Records 3           B - The practice has a system for transferring
1 point             and acting on information about patients seen
                    by other doctors out of hours.
Records 8           C - There is a designated place for the
1 point             recording of drug allergies and adverse
                    reactions in the Comments and these are
                    clearly recorded.
Records 9           A - For repeat medicines, an indication for the
4 points            drug can be identified in the records (for drugs
                    added to the repeat prescription with effect
                    from 1 April 2004). Minimum Standard 80%.
Records 11          A - The blood pressure of patients aged 45
10 points           and over is recorded in the preceding 5 years
                    for at least 65% of patients.
Records 13          C - There is a system to alert the out-of-hours
2 points            service or duty doctor to patients dying at
                    home.
Records 15          A - The practice has up-to-date clinical
25 points           summaries in at least 60% of patient records.
Records 17          A - The blood pressure of patients aged 45
5 points            and over is recorded in the preceding 5 years
                    for at least 80% of patients.
Records 18          A - The practice has up-to-date clinical
8 points            summaries in at least 80% of patient records.
Records 19          A - 80% of newly registered patients have had
7 points            their Comments summarised within 8 weeks of
                    receipt by the practice.
Records 20          A - The practice has up-to-date clinical
12 points           summaries in at least 70% of patient records.
Records 21          A - Ethnic origin is recorded for 100% of new
1 point             registrations.
Records 22          A - The percentage of patients aged over 15
11 points           years whose Comments 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%).




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Information for Patients

Indicator           Description                                         Practice      Any   Practice
                                                                        Not           Comments
                                                                        Aspiring
Information 3       A - The practice has arrangements for patients
1 point             to speak to GPs and nurses on the telephone
                    during the working day.
Information 4       B - If a patient is removed from a practice‟s
1 point             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.
Information 5       A - The practice supports smokers in stopping
2 points            smoking by a strategy which includes
                    providing literature and offering appropriate
                    therapy.
Information 7       A - Patients are able to access a receptionist
1.5 points          via telephone and face to face in the practice,
                    for at least 45 hours over 5 days, Monday to
                    Friday, except where agreed with the PCO.


Education and Training

Indicator           Description                                            Practice      Any   Practice
                                                                           Not           Comments
                                                                           Aspiring
Education 1         B - There is a record of all practice-employed
4 points            clinical staff having attended training/updating in
                    basic life support skills in the preceding 18
                    months.
Education 4         B - All new staff receive induction training.
3 points
Education 5         B - There is a record of all practice-employed staff
3 points            having attended training/updating in basic life
                    support skills in the preceding 36 months.
Education 6         A - The practice conducts an annual review of
3 points            patient complaints and suggestions to ascertain
                    general learning points which are shared with the
                    team.
Education 7         A - The practice has undertaken a minimum of
4 points            twelve significant event reviews in the past 3
                    years which could include:
                    Any death occurring in the practice premises;
                    New cancer diagnoses;
                    Deaths where terminal care has taken place at
                    home;
                    Any suicides;
                    Admissions under the Mental Health Act
                    Child protection cases;
                    Medication errors;
                    A significant event occurring when a patient may
                    have been subjected to harm, had the
                    circumstance/outcome been different.
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Indicator           Description                                             Practice   Any   Practice
                                                                            Not        Comments
                                                                            Aspiring
Education 8         C - All practice-employed nurses have personal
5 points            learning plans which have been reviewed at
                    annual appraisal.
Education 9         C - All practice-employed non-clinical team
3 points            members have an annual appraisal.
Education 10        A - The practice has undertaken a minimum of
6 points            three significant event reviews within the last year.




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Practice Management

Indicator           Description                                   Practice   Any  Practice
                                                                  Not        Comments
                                                                  Aspiring
Management 1  C - Individual healthcare professionals have
1 point       access to information on local procedures
              relating to Child Protection.
Management 2  A - There are clearly defined arrangements for
1 point       backing      up    computer      data,   back-up
              verification, safe storage of back-up tapes and
              authorisation for loading programmes where a
              computer is used.
Management 3  C - The Hepatitis B status of all doctors and
0.5 points    relevant practice-employed staff is recorded
              and immunisation recommended if required in
              accordance with national guidance.
Management 4  No grade - The arrangements for instrument
1 point       sterilisation comply with national guidelines as
              applicable to primary care.
Management 5  A - The practice offers a range of appointment
3 points      times to patients, which as a minimum should
              include morning and afternoon appointments
              five mornings and four afternoons per week,
              except where agreed with the PCO.
Management 6  B - Person specifications and job descriptions
2 points      are produced for all advertised vacancies.
Management 7  B - The practice has systems in place to
3 points      ensure regular and appropriate inspection,
              calibration, maintenance and replacement of
              equipment including:
                   A defined responsible person;
                   Clear recording;
                   Systematic pre-planned schedules;
                   Reporting of faults.
Management 8  A - The practice has a policy to ensure the
1 point       prevention of fraud and has defined levels of
              financial responsibility and accountability for
              staff    undertaking     financial   transactions
              (accounts, payroll, drawings, payment of
              invoices, signing cheques, petty cash,
              pensions, superannuation etc.)
Management 9  A - The practice has a protocol for the
3 points      identification of carers and a mechanism for
              the referral of carers for social services
              assessment.
Management 10 B - There is a written procedures manual that
2 points      includes staff employment policies including
              equal opportunities, bullying and harassment
              and sickness absence (including illegal drugs,
              alcohol and stress), to which staff have
              access.




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Medicines Management

Indicator           Description                                          Practice   Any   Practice
                                                                         Not        Comments
                                                                         Aspiring
Medicines 2         C - The practice possesses the equipment and
2 points            in-date emergency drugs to treat anaphylaxis.
Medicines 3         C - There is a system for checking the expiry
2 points            dates of emergency drugs on at least an annual
                    basis.
Medicines 4         A - The number of hours from requesting a
3 points            prescription to availability for collection by the
                    patient is 72 hours or less (excluding weekends
                    and bank/local holidays).
Medicines 6         A - The practice meets the PCO prescribing
4 points            adviser at least annually and agrees up to three
                    actions related to prescribing.
Medicines 7         C - Where the practice has responsibility for
4 points            administering regular injectable neuroleptic
                    medication, there is a system to identify and
                    follow up patients who do not attend.
Medicines 8         A - The number of hours from requesting a
6 points            prescription to availability for collection by the
                    patient is 48 hours or less (excluding weekends
                    and bank/local holidays).
Medicines 10        No grade - The practice meets the PCO
4 points            prescribing adviser at least annually, has agreed
                    up to three actions related to prescribing and
                    subsequently provided evidence of change.
Medicines 11        A - A medication review is recorded in the notes
7 points            in the preceding 15 months for all patients being
                    prescribed four or more repeat medicines.
                    Standard 80%.
Medicines 12        A - A medication review is recorded in the notes
8 points            in the preceding 15 months for all patients being
                    prescribed repeat medicines. Standard 80%.




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PATIENT EXPERIENCE

Indicator         Description                                             Practice   Any   Practice
                                                                          Not        Comments
                                                                          Aspiring
PE 1              Length of Consultation
33 points         A - The length of routine booked appointments
                  with the doctors in the practice is not less than 10
                  minutes. (If the practice routinely sees extras
                  during booked surgeries, then the average
                  booked consultation length should allow for the
                  average number of extras seen in a surgery
                  session. If the extras are seen at the end, then it
                  is not necessary to make this adjustment.)
                  For practices with only an „open surgery‟ system,
                  the average face-to-face time spent by the GP
                  with the patient is at least 8 minutes.
                  Practices that routinely operate a mixed economy
                  of booked and open surgeries should report on
                  both criteria.
PE 2              Patient Surveys (1)
25 points         A - The practice will have undertaken an
                  approved patient survey each year.
PE 5              Patient Surveys (2)
20 points         A - The practice will have undertaken a patient
                  survey each year and, having reflected on the
                  results, will produce an action plan that:
                      1. Summarises the findings of the survey.
                      2. Summarises the findings of the previous
                          year‟s survey.
                      3. Reports on the activities undertaken in the
                          past year to address patient experience
                          issues.
PE 6              Patient Surveys (3)
30 points         A - The practice will have undertaken a patient
                  survey each year and, having reflected on the
                  results, will produce an action plan that:
                      1. Sets priorities for the next 2 years;
                      2. Describes how the practice will report the
                          findings to patients (for example, posters
                          in the practice, a meeting with a patient
                          practice group or a PCO approved patient
                          representative.)
                      3. Describes the plans for achieving the
                          priorities, including indicating the lead
                          person in the practice.
                      4. Considers the case for collecting
                          additional      information     on    patient
                          experience, for example through surveys
                          of patients with specific illnesses, or
                          consultation with a patient group.




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ADDITIONAL SERVICES

Cervical Screening

Indicator           Description                                            Practice      Any  Practice
                                                                           Not           Comments
                                                                           Aspiring
CS1                 No grade - The percentage of patients aged from
11 points           25 to 64 (in Scotland from 21 to 60) whose notes
                    record that a cervical smear has been performed
                    in the last five years Standard 25 – 80%.
CS5                 C - The practice has a system for informing all
2 points            women of the results of cervical smears.
CS6                 A - The practice has a policy for auditing its
2 points            cervical screening service, and performs an audit
                    of inadequate cervical smears in relation to
                    individual smear-takers at least every 2 years.
CS 7                A - The practice has a protocol that is in line with
7 points            national guidance and practice for the
                    management of cervical screening, which includes
                    staff training, management of patient call/recall,
                    exception reporting and the regular monitoring of
                    inadequate smear rates.

Child Health Surveillance

Indicator           Description                                            Practice       Any  Practice
                                                                           Not            Comments
                                                                           Aspiring
CHS 1               C - Child development checks are offered at
6 points            intervals that are consistent with national
                    guidelines and policy.

Maternity Services

Indicator           Description                                            Practice      Any   Practice
                                                                           Not           Comments
                                                                           Aspiring
MAT 1               A - Ante-natal care and screening are offered
6 points            according to current local guidelines.

Contraceptive Services

Indicator           Description                                      Practice         Any   Practice
                                                                     Not              Comments
                                                                     Aspiring
Con 1               A - The team has a written policy for
1 point             responding to requests for emergency
                    contraception.
Con 2               A - The team has a policy for providing pre-
1 point             conceptual advice.




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Appendix 3 – PCT Standards for Policies and Procedures
Introduction

This document aims to provide independent contractors with guidance on writing policies and
procedures. For further assistance you may also contact the Clinical Governance Facilitators.

This document states the minimum requirements for QOF policies/protocols and procedures.
However, it is just as important that all relevant staff are involved in the production,
implementation, adherence and review of all Practice policies and procedures.

This guidance is not to be considered as definitive. It aims to assist practice staff with producing
documents to meet the Quality and Outcomes Framework (QOF) requirements of the new GMS
contract.

Definitions
Policy
Policy - the rules and forms of management; wisdom in managing.

       A policy is an approved and authoritative written statement requiring specific action(s) or
        responses to be adhered to. Plain English should be used – it should be clear, succinct
        and easily understood by the reader. Jargon should not be used.
       A policy is an overall guide which sets the boundaries within which action will take place,
        and should reflect the philosophy of the organisation or department. It should be general,
        yet comprehensive.

Procedure
Procedure - manner of proceeding; a step taken.

       A procedure is a written outline that directs action in a particular situation normally within
        the framework of a policy. It is a series of related steps designed to accomplish a specific
        task in a specified chronological order.
       Procedures should be written in step-by-step detail, so as to require only minimal
        interpretation, and include correctly completed examples where appropriate.
       A protocol is similar to a procedure – it is a set of rules or formalities for any procedure or
        a record of agreement.

Minimum Requirements

    The policy or procedure should be identifiable as belonging to your Practice. The Practice
        logo or name should be clearly visible on the document.
       The name and job title of the author of the policy or procedure should be identified.
       The release date or effective date should be shown.
       The date the document is due to be reviewed should be stated.
       Who will do the review should be identified – by job title rather than name as this could
        change if staff members change.
       The title of the document should reflect the content.
       If the policy/procedure relates to another document, add these references.
       Include a reference to where the document is stored on the computer.
       State who the policy/procedure applies to, and any exceptions
       Have an auditable system to ensure that all staff are aware of the policies and any
        changes that are made.

   It may be helpful to put the job titles of those responsible for carrying out the procedure on the
   top of the document (with a policy it generally affects all staff so this is not so relevant).
Appendix 4 – QOF Process 07/08 Flow Chart

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                             PCT sends Declaration to Practice
     Appendix 5 – PCT Informal Dispute Resolution Flow Chart


                 Practice QOF Lead submits concerns in writing to PCT Head of
                 Clinical Governance

                 Informal discussions take place between the practices PCT QOF
                 Team and the Practice. Grade C Evidence may be asked for at
14 Days          this stage.



                 Head of Clinical Governance, or deputy, reviews evidence and
                 endeavours to find informal resolution within 14 days.


                 The Practice may submit further clarification, or the PCT QOF
                 Team can request further clarification at any stage in this process.




                 If no agreement reached within 14 days, case passed to QOF
                 Quality Assurance Panel who will meet within 14 days to consider
                 the dispute



                  The Panel reviews evidence, where necessary requests further
                  clarification from the practice or PCT QOF Team and endeavours
                  to find formal resolution.


 35 days
                 The Quality Assurance Panel to make decision within 14 days of
                 meeting.


                 Chair of Quality Assurance Panel to advise both the Practice and
                 PCT Executive Team of decision within 7 days of decision being
                 made.


                 Within 1 month of the decision the contractor can lodge a formal
                 dispute under the LMC‟s Dispute Resolution Procedure (Appendix
                 7) with the PCT‟s CEO




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Appendix 6 Grade A evidence for submission by 31.3.08 for PPV
Indicator            Description                                                 Evidence
PC 2                 Ongoing Management                                          Written evidence to the
3 points             The practice has regular (at least 3-monthly)               PCO describing the
                     multidisciplinary case review meetings where all            system for initiating and
                     patients on the palliative care register are discussed.     recording meetings.
Information 5        A - The practice supports smokers in stopping               Copy of Strategy
2 points             smoking by a strategy which includes providing
                     literature and offering appropriate therapy.
Education 6          A - The practice conducts an annual review of patient       Reports/minutes of
3 points             complaints and suggestions to ascertain general             discussion - Submit to
                     learning points which are shared with the team.             PCT
Education 7          A - The practice has undertaken a minimum of twelve         Copy of reports in form
4 points            significant event reviews in the past 3 years which          consistent with either of 2
                    could include:                                               methods described in Ed
                           Any death occurring in the practice premises;        10. Submit if not
                           New cancer diagnoses;                                achieved in 05/06 or
                           Deaths where terminal care has taken place at        06/07
                               home;
                           Any suicides;
                           Admissions under the Mental Health Act
                           Child protection cases;
                           Medication errors;
                     A significant event occurring when a patient may have
                     been        subjected      to     harm,       had     the
                     circumstance/outcome been different.
Education 10         A - The practice has undertaken a minimum of three          Copy of SEA reports in
6 points             significant event reviews within the last year.             form consistent with
                                                                                 either of 2 methods
                                                                                 described in Ed 10
                                                                                 including evidence that
                                                                                 this has been shared with
                                                                                 the primary health care
                                                                                 team - submit to PCT.
Management 2         A - There are clearly defined arrangements for              Copy of practice policy
1 point              backing up computer data, back-up verification, safe
                     storage of back-up tapes and authorisation for loading
Medicines 6          A - The practice meets the PCO prescribing adviser at       Monitored through Head
4 points             least annually and agrees up to three actions related       of Medicines
                     to prescribing.                                             Management
Medicines 10         No grade - The practice meets the PCO prescribing           Monitored through Head
4 points             adviser at least annually, has agreed up to three           of Medicines
                     actions related to prescribing and subsequently             Management
                     provided evidence of change.
PE 5                 Patient Surveys (2)                                         Submit Action Plan
20 points            A - The practice will have undertaken a patient survey
                     each year and, having reflected on the results, will
                     produce an action plan that:
                          Summarises the findings of the survey.
                          Summarises the findings of the previous
                             year‟s survey.
                     Reports on the activities undertaken in the past year to
                     address patient experience issues.

PE 6                 Patient Surveys (3)                                         Submit Action Plan
30 points            A - The practice will have undertaken a patient survey
                     each year and, having reflected on the results, will
                     produce an action plan that:
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Indicator            Description                                                  Evidence
                            Sets priorities for the next 2 years;
                            Describes how the practice will report the
                             findings to patients (for example, posters in
                             the practice, a meeting with a patient/practice
                             group       or    a    PCO-approved        patient
                             representative.)
                          Describes the plans for achieving the
                             priorities, including indicating the lead person
                             in the practice.
                          Considers the case for collecting additional
                             information on patient experience, for example
                             through surveys of patients with specific
                             illnesses, or consultation with a patient group.
CS6                  A - The practice has a policy for auditing its cervical      Submit audit that includes
2 points             screening service, and performs an audit of                  all elements as stated in
                     inadequate cervical smears in relation to individual         QOF Practice Guidance
                     smear-takers at least every 2 years.                         (every 2 years)
CS 7                 A - The practice has a protocol that is in line with         Submit protocol
7 points             national guidance and practice for the management of
                     cervical screening, which includes staff training,
                     management of patient call/recall, exception reporting
                     and the regular monitoring of inadequate smear rates.
Mat 1                A - Ante-natal care and screening are offered                Submit guidelines
6 points             according to current local guidelines




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    Appendix 7 LMC Local Dispute Resolution Procedure

                                                                                                     February 07
1. Introduction

On occasions Primary Medical Services Contractors (contractors) may disagree with decisions
made by PCTs in respect to their contracts. Disputes may arise over decisions about contractual
sanctions and termination, remuneration, practice area and „opt-outs‟. Under such circumstances
contractors have the right of appeal against such a decision and to request that it is resolved
through a series of dispute resolution processes. This paper sets out the procedures that must be
undertaken by a PCT at a local level and goes on to explain the next stages. It is expected that
most contractual disputes will be resolved informally as part of the normal contractual relationship
before entering into formal procedures.

The paper sets out a framework for a formal local dispute resolution process when the informal
channels have failed to find a mutually agreeable solution, i.e. informal face-to-face discussion
between the Contractor and the PCT. In respect of GPs it is governed by the GMS & PMS
regulations 20041.

Assignment of patients to contractors with closed lists: It should be noted that disputes around
assignment of patients to contractors with closed lists are governed by Paragraph 36, Schedule
6, Part 2 “Patients” of the National Health Services (General Medical Services Contracts)
Regulations 2004 and Paragraph 35 Schedule 5, part 2 “Patients” of the National Health Services
(Personal Medical Services Agreements) Regulations 2004, and dealt with in section 7 of this
paper.

NHS dispute resolution procedure (paragraph 101): If, however, the formal local procedure
fails then either contractors or PCTs can, under the regulations, within three years beginning on
the date on which the matter giving rise to the dispute happened or should reasonably have come
to the attention of the party wishing to refer the dispute, refer a dispute to the Secretary of State
for determination. Thus the parties concerned should endeavour to resolve a dispute well within
the three year period allowing adequate time to refer the matter to the Secretary of State if
necessary.

2. Informal process

Paragraphs 99, and 93, in the GMS and PMS regulations schedules1 respectively, put an
expectation upon contractors and PCTs to make every reasonable effort to communicate and co-
operate with each other to resolve disputes before considering referring the dispute for
determination in accordance with the formal, local dispute resolution procedure, or to the Courts
(if the contractor does not have NHS Body status).        Indeed the formal process cannot be
activated until the informal process has been exhausted. Either party might wish to involve the
LMC at this stage in an advisory or mediation role.

Informal resolution helps develop and sustain a partnership approach between practices and the
PCT, as well as avoiding bureaucracy and cost for both parties. Informal resolution might benefit
from the involvement of a suitably qualified conciliator or mediator.

3. Stage 2 – The Formal Local Process


3 (a) Scope of the procedure


 Schedule 6, part 7 “Dispute Resolution” of the National Health Services (General Medical Services Contracts)
1

Regulations 2004; and Schedule 5, part 7 “Dispute Resolution” of the National Health Services (Personal Medical
Services Agreements) Regulations 2004.
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This procedure applies to all disputes arising from decisions within the jurisdiction of the PCT,
excluding those areas covered by separate procedures i.e. it will not apply to:
    The implementation of national guidance locally, where there is no choice for the PCT
       other than to apply;
    To list closure or patient assignment to closed lists where there are separate procedures,
    Sanctions imposed on a contract or termination of a contract.

This procedure applies to all contractors working under the new General Medical Services and
Personal Medical Services contracts within Bedfordshire and Hertfordshire, and is
complementary to other existing arrangements, for example using the Family Health Services
Appeals Unit.

If a number of similar disputes arise, leading to Formal Local Dispute Resolution, the PCT,
following liaison with the LMC, might consider all such cases together.

3 (b) PCT Local Dispute Resolution Panel

All contractors who are aggrieved by a decision of the PCT within whose boundaries they operate
can lodge a request for “Formal Local Dispute Resolution” in writing, including the grounds for the
request, to the Chief Executive of the Primary Care Trust. Under these circumstances the PCT
will set up a Local Dispute Resolution Panel (LDRP) to hear the dispute and make a
determination.

The panel will consist of:

       A PCT Chief Executive or Senior PCT Primary Care Manager from another PCT
       A Non Executive Director
       A patient representative (this may be the Non Executive Director if appropriate)
       An LMC (or other professional body) representative

Upon formation, the LDRP will agree a Chair. Should any of the panel members find it necessary
to declare an interest in the dispute which is being considered, the Chairman will seek to
approach another PCT/patient representative/LMC representative to nominate alternative panel
members.

3 (c) Timescales for the Local Dispute Resolution Panel

Responding to the request for Formal Local Dispute Resolution

If a contractor requests formal dispute resolution, the PCT shall acknowledge receipt of the
request for formal Local Dispute Resolution, in writing, within 3 working days of receipt of a
written request, explaining the procedure to be carried out by the PCT. Likewise, if the PCT
requests formal dispute resolution, the contractor shall acknowledge receipt of the request within
3 working days of receipt of the written request (this is in line with the NHS complaints
procedure).

The Hearing

The Chair of the LDRP will be asked to arrange a meeting of the LDRP to hear the dispute, and
ensure that all parties are notified of the date, time and location of the hearing. The hearing
should be held within 25 working days of the request being lodged by the Contractor(s) or the
PCT, but with the agreement of both parties to the hearing may be delayed to a date agreed by
both parties. The Chair of the LDRP will ensure that at least 10 working days notice of the date
of the hearing will be given to all participants.


4. The Hearing

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4 (a) Documentation

All the relevant documentation, including the request for Formal Local Dispute Resolution will be
passed to the Chair of the LDRP and then to panel members for consideration before the
hearing.

4 (b) Contractor(s) Representation

The contractor(s) will have the right to be supported at the LDRP hearing by an LMC member,
BMA representative, or a friend (or other appropriate professional body colleague). The
supporting colleague will not normally be allowed to speak to the panel. If a solicitor accompanies
the contractor(s), the Chair of the Panel will make it clear that the panel is not a statutory tribunal.

Professional advisors, such as solicitors or accountants, will not normally attend in a
representative role unless especially requested in advance of the hearing.

4 (c) Witnesses

Either party has the right to call witnesses. Any witnesses shall be present at the panel hearing
only while they are giving evidence.

4 (d) Procedure at the LDRP Hearing

The discussions of the Panel will remain confidential.

The Chair of the Panel will keep a record (or arrange for minutes to be taken) of the hearing.

The contractor(s) and the PCT will be asked to present their cases and may call witnesses.
Members of the Panel will be given the opportunity to ask any questions relevant to the case.

Following the presentation of their case the contractor(s) and PCT will withdraw and the panel will
deliberate. The panel will reach a decision on the case and notify the contractor and the PCT
Chief Executive of the decision including any recommendations in writing within seven days after
the hearing. Where appropriate, the decision will be reported to a full meeting of the Board of the
Primary Care Trust for information.

If no solution can be found locally it will be open to either party to the dispute to refer the matter to
Strategic Health Authority (SHA) or to the Family Health Services Appeals Unit (FHSAU) in line
with paragraphs 101 and 95 of the GMS and PMS regulations respectively, for dispute resolution
under the „NHS Dispute Resolution Procedure‟.

5. Stage 3 - Appeal to the Secretary of State through the FHSAU - NHS Dispute Resolution
Procedure2

If an issue cannot be satisfactorily resolved through local Dispute Resolution, an appeal can be
lodged by either party to the SHA or FHSAU. Where a dispute arises out of or in connection with
a NHS contract either party may refer to matter to the FHSAU or, where appropriate, the
Strategic Health Authority for consideration and determination2. The FHSAU can appoint an
adjudicator to act on its behalf.

Written requests must be directed to the FHSAU within three years beginning on the date on
which the matter giving rise to the dispute happened or should reasonably have come to the
attention of the party wishing to refer the dispute (effectively referring a dispute to the Secretary


 The procedures are set out in Paragraphs 36, and 101 of Schedule 6, of the National Health Services (General
2

Medical Services Contracts) Regulations 2004; and paragraphs 35 and 95 of Schedule 5 of the National Health Services
(Personal Medical Services Agreements) Regulations 2004, provide for the FHSAU to deal with most cases.

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of State for determination). Disputes should be addressed directly to the FHSAU and must
include:
     The names and addresses of the parties to the dispute
     A copy of the contract; and
     A brief statement describing the nature and circumstances of the dispute.


6. Disputes arising from Contract Sanctions and Termination of Contracts3

Disputes concerning sanctions or contract termination must be referred to the FHSAU within 28
days3 of the imposition of the sanction or termination of the contract for NHS Dispute Resolution.
The contractor must notify in writing the PCT that it has requested NHS Dispute Resolution.
During the NHS Dispute Resolution procedure the relevant body (i.e. the PCT) shall not impose
the sanction or terminate the contract until determination permits the relevant body to do so.

The resulting determination will be binding on both parties.

7. Disputes arising from Assignment of patients to practices with ‘Closed Lists’4

Disputes concerning assignment of patients to practices with „Closed Lists‟ must be referred to
the FHSAU within 7 days of the determination of the PCT‟s assessment panel, for NHS Dispute
Resolution4.

The resulting determination will be binding on both parties.

Disputes where the contractor is not an NHS body can be referred to either the FHSAU or
a competent court.

It is recommended this policy and procedure will be reviewed not later than 1 year from the date
detailed below by the PCTs in conjunction with the Local Medical Committee.

Date agreed by Bedfordshire PCTs – 16th January 2007

Date agreed by Hertfordshire PCTs – 13th February 2007




3
  Disputes arising from Contract Sanctions and Termination of Contracts are governed by paragraphs 118 and 119
respectively of Part 8, of schedule 6, of the National Health Services (General Medical Services Contracts) Regulations
2004; and paragraphs 110 and 111 respectively of part 8, schedule 5 of the National Health Services (Personal Medical
Services Agreements) Regulations 2004.
4
  Disputes arising from assignment of patients to practices with „Closed Lists‟ are governed by paragraph 36 of Part 2,
of schedule 6, of the National Health Services (General Medical Services Contracts) Regulations 2004; and paragraph
35 part 2, schedule 5 of the National Health Services (Personal Medical Services Agreements) Regulations 2004 .
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