Empowering GPs to Work Collectively toImprove Patient Care

Mel Varvel

Dr Richard Healicon

NHS Improving Quality

Introduction• NHS Improving Quality• An ambitious call to action• System levers and drivers• Roles and responsibilities• Carrots and sticks• The GRASP Approach

NHS Improving Quality• Set up from 1 April 2013 and hosted by NHS England

• Improving health outcomes across England by providing improvement and change expertise

• An evidence-based organisation that is aligned to the current needs and challenges of the NHS

• Builds on the wealth of knowledge, expertise and experience that has gone before

• The ‘go to’ organisation leading improvement in England

• Working with partners in design and delivery across the service

Five Transformational Change Programmes

• Living longer lives

• Promoting and enabling integrated care and support

• 7 day services

• Patient safety

• Valuing patient experience

Living Longer Lives• Supporting implementation of the CVD Outcomes

Strategy (and NHS Health Check)• Raising public awareness of symptoms and supporting

early diagnosis of disease• Engaging with clinicians and primary care in the nation’s

biggest killers

An Ambitious Call to Action

System Levers and Drivers• GMS Contract• Enhanced service contracts (DES)• Extended service contracts (LES)• Quality and Outcomes Framework• From April 2014

– Named, accountable GP for >75s– Greater role in reducing avoidable emergency admissions

• CCG Outcomes Indicator Set (CCG OIS)

Roles and Responsibilities

Commissioning bodies

Funding streams and contracts

NHS England

Core Contracts Voluntary/ additional contracts

Clinical Commissioning Groups

Local Authorities

GP Provider organisations (almost all payments go to the GP provider organisation and not individual GPs)

GPs supply services to the NHS via three contracting routes.• GMS

(nationally agreed)

• PMS (locally agreed)

• APMS (locally agreed)

Quality and Outcomes Framework (QOF)GP practices are rewarded according to their performance against a number of indicators

Enhanced ServicesPayments currently linked to extended hours of service provision, minor surgery and other enhanced clinical services

Community-based services(formerly Local Enhanced Services)

Public HealthIncludes things like screening and immunisation from April 2014

Flow of funding and contracting in general practice under current system

Carrots and Sticks

From Compliance to Commitment

The GRASP Approach• Simple audit tool to improve the management of a number of LTCs• Collective goal setting

– no minimum performance standard

• Bottom up approach– No hierarchical control

• Voluntary participation– Not delivered through formal control mechs

• Delivery through shared commitment– Not performance managed

• A vehicle for engagement and improvement– GPs firmly in the driving seat

The GRASP Suite of Audit Tools

Dr Richard Healicon

Programme Delivery Lead, Living Longer Lives

Mel Varvel

Improvement Manager, Living Longer Lives

Outline• Introduction- GRASP Suite• Focus on GRASP-AF• Guidance on management of stroke risk in AF• Tools to help: GRASP-AF and CHART Online• Other toolkits• Summary• How to access the GRASP Suite

GRASP toolkits• Free primary care audit tools• AF, COPD and HF• Aligned to NICE/ ESC guidance• Each has a case finder• Compatible with all GP systems in England• Stand alone (patient identifiable)• CHART Online (anonymised data)

GRASP-AF• Guidance on Risk Assessment and Stroke Prevention in AF

Stroke is a frequent complication of AF• Stroke is the leading complication of AF• Patients with AF have a five-fold higher stroke risk than those without AF• Without preventive treatment, each year approximately 1 in 20 patients (5%)

with AF will have a stroke• It is estimated that 15% of all strokes are caused by AF and that 12,500

strokes per year in England are directly attributable to AF

Stroke is a serious complication of AF• Stroke in AF is associated with a heavy burden of morbidity and mortality• AF related stroke is usually more severe than stroke due to other causes• Compared with other stroke patients, those with AF are more likely to:

– Have cortical deficit (e.g. aphasia), severe limb weakness and diminished alertness, and be bedridden on admission

– Have longer in-hospital stay with a lower rate of discharge to their own home

• The mortality rate for patients with AF is double that in people with normal heart rhythm

Stroke Risk Stratification

Stroke risk in AF: CHADS2

Stroke risk in AF: CHA2DS2VASc

Stroke risk in AF

ESC Guidelines Focussed Update 2012

GRASP-AF• One of three free audit tools developed by NHS IQ and PRIMIS• Case Finder• Identifies patients with a history of atrial fibrillation

• Searches for co-morbidities and calculates both a CHADS2 and CHA2DS2-VASc score

• Searches for current medication- warfarin, aspirin or newer oral anticoagulant• Searches for recorded reasons for NOT treating with warfarin• Gives a simple alert for those at high risk and not on warfarin or newer oral

anticoagulant

The GRASP-AF toolkit in action

CHART Online• Voluntary upload of data to CHART online• Web based analysis tool with a variety of comparative viewing options

available• Secure and restricted access• For both primary care staff and commissioners

Clarification about security• Only anonymised patient level data is uploaded and that this is transmitted

and stored securely• Viewing data in CHART Online is restricted to people registered on the

PRIMIS Profile Centre who are validated by either PRIMIS or NHS Improving Quality

• Users who are validated by PRIMIS or NHS Improving Quality will only be able to view a Practice's national code if given specific permission by the Practice

CHART Online data- managementSeptember 2013:

183,334 patients with a CHADS2≥2 in those 2,515 practices:

• 48.4% patients on oral anticoagulation (OAC) alone• 8.4% patients on OAC and aspirin• 34.5% patients on aspirin alone• 8.7% are not on either

Of those 79,082 patients not on OAC:

• 9.8% OAC declined• 3.6% contraindicated• 86.6% no reason given

Chart Online• Benchmark own practice against others in CCG• Benchmark CCG against others in SCN/ National• Practices control who sees their national identifier• Facility to email all in CCG to seek permission for this

CHART Online• Opportunity for

– GP/ Practice level audit- revalidation– CCG/ SCN level audit- improve together– Data sharing with SCNs/ AHSNs

Current Issues• Data sharing

– GPs are data controllers– How to share more widely- CCGs, SCNs, AHSNs,

NHS IQ

GRASP-COPD

GRASP-HF

Summary• Almost one third of GP practices in England using GRASP-AF and uploading

data to CHART Online• GRASP-AF is improving the way stroke risk in AF is managed; changes are

small but potential impact is great• NHS Improving Quality wants to build on the success of GRASP-AF by

developing a ‘suite’ of similar tools for other conditions.• GRASP-COPD is now available.• GRASP-HF is now available.

Getting GRASP

Getting GRASP

Reducing premature mortality: Supporting CCGs• Webpage resources & PDF version ‘Our

Ambition to Reduce Premature Mortality’ now on NHS England website. Produced with partner organisations (NHS IQ, PHE, Commissioning Assembly quality working group)

• Information on prevention, earlier diagnosis, case finding - including GRASP tools - & interventions likely to have greatest impact on reducing premature mortality.

• Further development of resources planned for April/May

• See www.england.nhs.uk/premature-mortality/

@NHSIQ

#GRASP_suite

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enquiries@nhsiq.nhs.uk

www.nhsiq.nhs.uk

Improving health outcomes across England

by providing improvement and change expertise.