Waking the sleeping giant

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Waking the sleeping giant

• Philippa Matthews FRCGP
• GP, Killick Street Health Centre, Kings Cross
• QOF Lead Sexual Health 07/09

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Waking the sleeping giant

• Levers for change in General Practice-
• Contractual
• Quality and Outcomes Framework QOF
• Educational
• nMRCGP and e-Learning for General Practice

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Is General Practice a giant?
Primary Care
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Sexual health services in GP
Essential
Minority of practices Vast majority of
practices (but technically can opt-out) All
practices
Enhanced
Additional
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Sexual health services in GP
Examples of relevant services Contraceptive
implants / IUDs Chlamydia screening HIV screening
pilots Contraception (mainly non-LARC) Cervical
screening Contract Care of people who are ill
acute or chronic Advice with respect to
health Onward referral SH Strategy Level 1 eg
STI and HIV testing Pregnancy testing referral
for abortion
Essential
Enhanced
Additional
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What are the levers for change?

• Contractual
• With PCTs
• Sexual health commissioners
• Practice based commissioning?
• Unclear!
• National contract
• QOF
• PMS mirrors national
• picture local QOF
• Local enhanced?

Education and assessment Specialist certificates
eg for Implant and IUD fitting Locally variable
hoops Entry level Teaching and assessment for
nMRCGP (compulsory) Optional for current
GPs DFSRH STIF RCGP ICSH Local initiatives NHS
CSP Variety of e-learning
Essential
Enhanced
Additional
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What are the levers for change?

• Contractual
• With PCTs
• Sexual health commissioners
• Practice based commissioning?
• Unclear!
• National contract
• QOF
• PMS mirrors national
• picture local QOF
• Local enhanced?

Education and assessment Specialist certificates
eg for Implant and IUD fitting Locally variable
hoops Entry level Teaching and assessment for
MRCGP (compulsory) Optional for current
GPs DFSRH STIF RCGP ICSH Local initiatives NHS
CSP Variety of e-learning
Essential
Enhanced
How successfully has the Strategy been able to
influence the levers?
Additional
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Why QOF matters
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Essential and additional services How important?

• 80 of contraception is provided in 1o care
  ONS 2007
• The NHS cervical screening programme is delivered
  
• by general practice
• General practice
• ...is well used and is one of the most popular
  public services
• ...has unmatched accessibility and geographical
  coverage
• Audit Commission 2002

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Is General Practice a giant?
Yes!
Primary Care
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But does General Practice have a role to play in
sexual health care?

• There is evidence that significant numbers of
• People with symptomatic, undiagnosed HIV
  infection
• People with symptomatic STIs
• Young women at risk of unwanted pregnancy
• Street based sex workers
• Men who have sex with men
• ..use their local general practice
• and only comparatively rarely will they
• be using a commissioned enhanced service

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Sexual health services in GP
Essential
Identifying and caring for people at risk
can only happen on a useful scale at the
essential/ additional levels. ie all practices
must become engaged, as far as possible to
address the problem of UNMET NEED by using
OPPORTUNISTIC APPROACHES
Additional
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Levers for change Additional and Essential
Services

• Contractual
• National contract
• QOF

Education and assessment Entry
level Teaching and assessment for MRCGP
(compulsory) Optional for current
GPs E-learning
Essential
Enhanced
Additional
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QOF money for old rope?

• The exceptional tale of exception reporting

Primary Care?
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QOF points

• Organisational Indicators
• eg The practice has a policy for provision of
  emergency contraception
• Clinical Indicators
• Eg 80 of patients with diabetes should have a
  blood pressure of x over x
• and the concept of exception reporting...

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Source Doran et al NEJM, 2008 359 274-84
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QOF advantages

• Most GPs less cynical than you might think?
• Huge scale - potential escape from piecemeal
  change (eg with chlamydia screening)
• Indicators lead to enormous discussion / learning
  within practices
• Can brings demonstrable changes to care and
  sometimes outcomes

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QOF indicators and sexual health the story so
far

• Reports on each selected clinical field were
  originally to be every 2 years
• First sexual health report (2005)
• missed opportunity, no clear QOF proposals
  made.
• Which leaves 07/08 and 08/09...
• www.npcrdc.ac.uk/QOF

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QOF Sexual Health 07/08

• Firm steer to avoid chlamydia screening
• Widespread consultation
• All proposed indicators vetted and scored by
• A group of experts
• IT and QOF experts
• 11 indicators put forward
• some organisational, some clinical

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QOF Sexual Health 07/08 Proposed
organisational indicators

• The practice has
• Up to date patient info on access to SH care
• A confidentiality policy
• Visible policy on access for young people
• Policy for promotion and provision of testing for
  blood borne viruses

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07/08 proposed indicator SH1

• The practice has up to date poster and leaflet
  information visible and available to patients in
  the waiting area or at reception, making clear
  where and how patients can obtain advice on
  sexually transmitted infections, contraception,
  (including emergency contraception and
  long-acting methods of contraception), pregnancy
  testing, pregnancy counselling and abortion
  (including those services provided by the
  practice).

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07/08 proposed indicator SH4

• The practice has a written policy for the
  promotion and provision of testing for blood
  borne viruses (HIV, Hepatitis B and Hepatitis C).
• Guidance This should include reference to those
  relevant local demographic groups which may
  include individuals at higher risk. The practice
  leaflet or other relevant visible patient
  material should make reference to the
  availability of testing.

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QOF Sexual Health 07/08Proposed clinical
indicators

• Women should be given info on the prescribed
  contraceptive method
• Women on short-acting, or EHC, given info on LARC
• Women on short-acting or injectable (or given
  EHC) - assessed for risk of STIs

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07/08 proposed indicator SH10

• The percentage of women prescribed emergency
  hormonal contraception at least once in the year
  by the practice, who have received information
  from the practice about long acting reversible
  methods of contraception at the time of, or
  within 1 month of, the prescription.

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QOF Sexual Health 07/08

• 07/08 report scuppered because of dispute in
  contract negotiations....no new health domain
  introduced
• Full report available on www.npcrdc.ac.uk/QOF

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QOF Sexual Health 08/09

• Strong steers to
• address LARC - and chlamydia!
• avoid organisational indicators
• Nine indicators proposed
• 2 LARC ones from 07/08 report
• remainder on chlamydia, some on risk assessment
• No opportunity for evaluation of any new
  indicators.
• Chlamydia almost impossible to tackle because of
  existing, and differing, UK nation policies

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QOF Sexual Health 08/09

• 2 LARC indicators got through
• Indicators relating to chlamydia rejected

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Top 1000 priorities for today
GPs limited? - or asleep? - on sexual health?
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QOF What next?

• NICE have taken over management of QOF
• Will work in collaboration with other
  organisations eg
• RCGP, York Health Economics Consortium
• Stronger emphasis on
• Cost effectiveness
• Linking with NICE guidance
• May introduce local flexibility
• ?Organisational indicators likely to go?

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QOF Who will engage?

• Who will engage with the new QOF process?
• RCGP
• DH?
• Independent Advisory Group on Sexual Health
  HIV?
• Expert Advisory Group on AIDS?
• Medfash?
• Your organisation?
• You?
• http//www.nice.org.uk/aboutnice/qof/qof.jsp

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nMRCGP

• Another lever influenced by the National Strategy

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nMRCGP

• Entry qualification for GPs
• A curriculum for General Practice
• Includes a statement on sexual health
• RCGP e-learning - launched in July
• 15,000 GPs and GP specialty trainees already
  enrolled
• Includes a module on sexual health
• Potential audience 40,000 GPs and 20,000 PNs

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Sexual health module the most completed
sessions of all modules!

• I found this a very useful module, probably the
  most interesting one I have come across in a long
  time. I really like the short video clips.
• As a new GP Registrar, I found this an excellent
  module to help me prepare strategies for taking a
  sexual history in general practice.
• Learnt a lot and completely changed my
  practice.

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Q
O
F
Implants

• Gina the giant of general practice
• awakens!