Diabetes and the quality and outcomes framework
http://www.100md.com
《英国医生杂志》
Successful UK initiative highlights inequity of investments between sectors
The rapidly rising prevalence of diabetes in the United Kingdom demands an effective response from healthcare services.1 British general practitioners were among the first doctors in primary care worldwide to manage many aspects of diabetes care in their own practices,2 and by the millennium were providing systematic diabetes care.3 Primary care based interventions are cost effective—countries with strong primary healthcare systems have lower healthcare costs and healthier populations.4 The 2003 general medical services contract signalled the government's determination to invest in evidence based interventions in primary care and to encourage further expansion of chronic disease management, including diabetes care, into general practice.5 The contract introduced a quality and outcomes framework, designed to monitor the quality of the delivery of primary care.
In this week's BMJ Campbell and colleagues report that general practitioners were already improving effective care for three of the diseases covered by the framework.6 One of these was diabetes, which is assessed by 18 clinical indicators in the general medical services contract.7 Contract data shows the prevalence of diabetes is 3.3% in England and Scotland, 3.8% in Wales, and 2.8% in Northern Ireland, and in England more than 93% of general practices achieved the maximum points for diabetes care.w1 Most participating practices have set up active patient registers to facilitate call and recall for consultations.
The new general medical services contract built on the rigorous analyses undertaken to develop the four national service frameworks for diabetes—one for each country in the United Kingdom.8 The contract negotiators insisted that the new contract would be the same throughout the UK and largely ignored the patient focused elements such as information, education, and empowerment in the frameworks. The contract focuses on pharmaceutical interventions which are easily measured, and primary care organisations have reported that, concurring with Campbell and colleagues,6 prescribing in diabetes and cardiovascular prevention was increasing and increased after the new contract,9 reflecting both a rising diabetes incidence and more intensive management.
Although participation in the quality and outcomes framework was not a compulsory component of the new general medical services contract, practices soon realised that non-involvement would mean a loss of about a third of their income, potentially making them non-viable. The financial rewards from the contract have enabled practices to invest in staff and resources. Although the substantial investment in managing diabetes in primary care has been welcomed and has prompted considerable change, it has left those working in secondary diabetes care feeling beleaguered since there has been no similar investment in secondary care.10 Intensive micromanagement of staff in hospital trusts is further weakening morale.w2
Moving resources to primary care may be more about containing costs than attempting to improve global patient care, and it has resurrected the debate about who has primacy in diabetes care.11 The multifaceted interventions in the new general medical services contract have proved effective in both primary and secondary care,12 w3 and have yielded similar outcomes.w4 Given that the quality and outcomes framework has encouraged such uniform management of diabetes in primary care, this debate has become sterile.
An epidemic of diabetes demands a concerted approach across primary and secondary care, with active investment in both sectors. Research, guidelines, teaching, and training should be common between both sectors, with the opportunity for secondary care providers to spend some time working in the community. Although much care for people with diabetes will be in primary care, many patients will develop complications requiring the expertise of those in secondary care. The providers in this sector should be nurtured and rewarded as well, and services should have access to better information systems to manage and monitor the delivery and quality of care, although this may stretch limited resources.
While general practices have been implementing the contract and framework, some general practitioners have gone further, developing a special interest in diabetes, seeking further training, and providing additional services to primary care organisations.13 These initiatives have been poorly resourced, however, lacking a model job description or agreed remuneration, and are still evolving.w5
Though an effective response to the emerging epidemic of diabetes will be centred on primary care, ensuring that patients are empowered to play a key role in the management of their condition, secondary care has a role to play too. Over time, most patients will move between primary and secondary care according to their needs and the complexity of their complications, and it is essential that the service interfaces they traverse should be seamless. The mechanism of rewarding those who provide high quality diabetes care through the system of clinical indicators is proving effective and should now be extended to include all those providing care for diabetes patients.
Colin Kenny, general practitioner
(drckenny@aol.com)
Dromore Doctors Surgery, Dromore, County Down BT25 1BD
Primary Care p 1121
Extra references w1-w4 appear on bmj.com
Competing interests: CK is former chairman of the Primary Care Diabetes Society, but has no competing financial interests.
References
International Diabetes Federation. New diabetes prevalence model in the UK. www.globalnews.idf.org/2005/05/new_diabetes_pr.html (accessed 25 Aug 2005).
Thorn PA, Russell RG. Diabetic clinics today and tomorrow: mini-clinics in general practice. BMJ 1973;ii: 534-6.
Pierce M, Agarwal G, Ridout D. A survey of diabetes care in general practice in England and Wales. Br J Gen Pract 2000;50: 542-5.
Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001;51: 303-9.
NHS Confederation. New GMS contract. www.nhsconfed.org/gms/ (accessed 4 Sep 2005).
Campbell SM, Roland MO, Middleton E, Reeves D. Improvements in quality of clinical care in English general practice 1998-2003: longitudinal observational study. BMJ 2005;331: 1121-3.
NHS Health and Social Care Information Centre. Quality and outcomes framework information. www.ic.nhs.uk/services/qof (accessed 31 Aug 2005).
Diabetes UK. Diabetes service frameworks. www.diabetes.org.uk/frameworks/frameworks.htm (accessed 13 Sep 2005).
Prescription pricing authority. Volume and cost of prescribing. www.ppa.org.uk/news/vol_cost_presc.htm (accessed 3 Nov 2005).
Munro N, McIntosh C, Feher M. Shifting diabetes care: rhetoric and reality. Pract Diab Int 2005;22(5).
Hampton JR. The primacy of primary care. BMJ 1998;317: 1724-5.
Gaude P, Vedel P, Larsen N, Jensen GVH, Parving H, Pedersen O. Multifactorial interventions and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348: 383-93.
Department of Health. Guidelines for the appointment of general practitioners with a special interest in the delivery of clinical services: diabetes. London: DOH, 2003.
The rapidly rising prevalence of diabetes in the United Kingdom demands an effective response from healthcare services.1 British general practitioners were among the first doctors in primary care worldwide to manage many aspects of diabetes care in their own practices,2 and by the millennium were providing systematic diabetes care.3 Primary care based interventions are cost effective—countries with strong primary healthcare systems have lower healthcare costs and healthier populations.4 The 2003 general medical services contract signalled the government's determination to invest in evidence based interventions in primary care and to encourage further expansion of chronic disease management, including diabetes care, into general practice.5 The contract introduced a quality and outcomes framework, designed to monitor the quality of the delivery of primary care.
In this week's BMJ Campbell and colleagues report that general practitioners were already improving effective care for three of the diseases covered by the framework.6 One of these was diabetes, which is assessed by 18 clinical indicators in the general medical services contract.7 Contract data shows the prevalence of diabetes is 3.3% in England and Scotland, 3.8% in Wales, and 2.8% in Northern Ireland, and in England more than 93% of general practices achieved the maximum points for diabetes care.w1 Most participating practices have set up active patient registers to facilitate call and recall for consultations.
The new general medical services contract built on the rigorous analyses undertaken to develop the four national service frameworks for diabetes—one for each country in the United Kingdom.8 The contract negotiators insisted that the new contract would be the same throughout the UK and largely ignored the patient focused elements such as information, education, and empowerment in the frameworks. The contract focuses on pharmaceutical interventions which are easily measured, and primary care organisations have reported that, concurring with Campbell and colleagues,6 prescribing in diabetes and cardiovascular prevention was increasing and increased after the new contract,9 reflecting both a rising diabetes incidence and more intensive management.
Although participation in the quality and outcomes framework was not a compulsory component of the new general medical services contract, practices soon realised that non-involvement would mean a loss of about a third of their income, potentially making them non-viable. The financial rewards from the contract have enabled practices to invest in staff and resources. Although the substantial investment in managing diabetes in primary care has been welcomed and has prompted considerable change, it has left those working in secondary diabetes care feeling beleaguered since there has been no similar investment in secondary care.10 Intensive micromanagement of staff in hospital trusts is further weakening morale.w2
Moving resources to primary care may be more about containing costs than attempting to improve global patient care, and it has resurrected the debate about who has primacy in diabetes care.11 The multifaceted interventions in the new general medical services contract have proved effective in both primary and secondary care,12 w3 and have yielded similar outcomes.w4 Given that the quality and outcomes framework has encouraged such uniform management of diabetes in primary care, this debate has become sterile.
An epidemic of diabetes demands a concerted approach across primary and secondary care, with active investment in both sectors. Research, guidelines, teaching, and training should be common between both sectors, with the opportunity for secondary care providers to spend some time working in the community. Although much care for people with diabetes will be in primary care, many patients will develop complications requiring the expertise of those in secondary care. The providers in this sector should be nurtured and rewarded as well, and services should have access to better information systems to manage and monitor the delivery and quality of care, although this may stretch limited resources.
While general practices have been implementing the contract and framework, some general practitioners have gone further, developing a special interest in diabetes, seeking further training, and providing additional services to primary care organisations.13 These initiatives have been poorly resourced, however, lacking a model job description or agreed remuneration, and are still evolving.w5
Though an effective response to the emerging epidemic of diabetes will be centred on primary care, ensuring that patients are empowered to play a key role in the management of their condition, secondary care has a role to play too. Over time, most patients will move between primary and secondary care according to their needs and the complexity of their complications, and it is essential that the service interfaces they traverse should be seamless. The mechanism of rewarding those who provide high quality diabetes care through the system of clinical indicators is proving effective and should now be extended to include all those providing care for diabetes patients.
Colin Kenny, general practitioner
(drckenny@aol.com)
Dromore Doctors Surgery, Dromore, County Down BT25 1BD
Primary Care p 1121
Extra references w1-w4 appear on bmj.com
Competing interests: CK is former chairman of the Primary Care Diabetes Society, but has no competing financial interests.
References
International Diabetes Federation. New diabetes prevalence model in the UK. www.globalnews.idf.org/2005/05/new_diabetes_pr.html (accessed 25 Aug 2005).
Thorn PA, Russell RG. Diabetic clinics today and tomorrow: mini-clinics in general practice. BMJ 1973;ii: 534-6.
Pierce M, Agarwal G, Ridout D. A survey of diabetes care in general practice in England and Wales. Br J Gen Pract 2000;50: 542-5.
Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001;51: 303-9.
NHS Confederation. New GMS contract. www.nhsconfed.org/gms/ (accessed 4 Sep 2005).
Campbell SM, Roland MO, Middleton E, Reeves D. Improvements in quality of clinical care in English general practice 1998-2003: longitudinal observational study. BMJ 2005;331: 1121-3.
NHS Health and Social Care Information Centre. Quality and outcomes framework information. www.ic.nhs.uk/services/qof (accessed 31 Aug 2005).
Diabetes UK. Diabetes service frameworks. www.diabetes.org.uk/frameworks/frameworks.htm (accessed 13 Sep 2005).
Prescription pricing authority. Volume and cost of prescribing. www.ppa.org.uk/news/vol_cost_presc.htm (accessed 3 Nov 2005).
Munro N, McIntosh C, Feher M. Shifting diabetes care: rhetoric and reality. Pract Diab Int 2005;22(5).
Hampton JR. The primacy of primary care. BMJ 1998;317: 1724-5.
Gaude P, Vedel P, Larsen N, Jensen GVH, Parving H, Pedersen O. Multifactorial interventions and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348: 383-93.
Department of Health. Guidelines for the appointment of general practitioners with a special interest in the delivery of clinical services: diabetes. London: DOH, 2003.