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CHDGP - Plans for the Pilot Stage

THE PILOT STAGE

Pioneer schemes have demonstrated that regular collection, analysis and feedback of comparative data to groups of practices is valuable in improving the use of GP systems, informing decision making in various ways that tend to improve resource usage and patient care, and supporting clinical audit. However, it was felt necessary to build on this experience with a larger group of projects and participating practices, before promoting the principles and techniques more widely. Therefore it was decided to set up and operate a Pilot Stage of CHDGP, which is scheduled to run from December 1997 to March 1999. During this time a number of local schemes will be operating as pilot sites, working with and being supported by the national project team.

Terms of Reference for Pilots

Pilots have agreed to work within certain parameters, the most significant of which are:

At the time of writing (December 1997) twelve pilot schemes or projects are active.

Local Pilots: (a) New Projects

Projects in Bedfordshire, Bromley, Lambeth Southwark and Lewisham, North West and South Lancashire, North Nottinghamshire, Oxfordshire and Southern Derbyshire have only recently started.

Bedfordshire Health Authority saw participation as an opportunity to launch an initiative to facilitate locality commissioning and clinical audit.

Bromley Health Authority were already working towards using GP data to inform commissioning and health needs assessment on a locality basis. They saw participation in CHDGP and the additional support available as providing impetus to speed up the process.

The project in Lambeth is managed by the local Multidisciplinary Audit Research Group, with clinical input from Kings College Department of Public Health, and support from the Health Authority. It is focused on practice health needs assessment, and builds upon some useful analysis and research work on hypertensive disease undertaken in 1996 based on data from 11 practices.

The Lancashire project is an R&D funded joint venture between North West and South Lancashire Health Authorities, with the aim of working with as many practices as possible with MIQUEST-compliant systems. This new initiative (Sharing Information in Primary Care (SIP)) commenced in July 1997, but follows a significant health needs assessment project conducted in 1995/96 which involved 25 practices throughout the county. The emphasis of this new project will be on practice development. The information generated will support self-audit, and help to identify gaps in care management as well as in data recording. It will also help practices to assess the needs of their population and their response to that need.

North Nottinghamshire Health Authority see the CHDGP project as a means of initiating a primary care information strategy and strengthening relationships between practices and the authority.

The Oxfordshire project will be managed from the MAAG, building on earlier comparative audit work with practices on asthma, heart disease and diabetes, and on an active Primary Care Computing Group.

Southern Derbyshire Health Authority view CHDGP and its agenda as complementary to existing plans to roll out clinical guidelines and their integration into GP systems.

Local Pilots: (b) Established Projects

Calderdale and Kirklees

This health needs assessment project has been running since early 1995. It was decided to focus the initial work on diabetes, because it was an area where GPs knew standards of care varied and data should be readily available. After definitions and coding problems were worked through, prevalence was found to be 50% higher than anticipated, and changes in services have been made as a result. Subsequently data has also been collected on heart disease and mental health. The success with the first three conditions has led to the GPs systematically reviewing a number of chronic disease programmes. Extensive use has been made of MIQUEST, to extract patient-based data as well as aggregates.

This project is the subject of a detailed case study leaflet published by the CHDGP project; copies are available from the project office.

Healthy East Enders

The Healthy East Enders project has been auditing the recording of health promotion/ prevention data by GPs and nurses on paper and computer medical records since 1987. It is managed by a team resident in the Department of Primary Care at Barts and Royal London School of Medicine. The project is now working with 16 practices in East London to facilitate the development of computerised disease registers for cardiovascular disease, asthma and diabetes. It is now also using MIQUEST software to carry out audits through electronic data extraction, and will extend collection to include more items in the CHDGP core data set.

Northumberland

The ‘Medics’ scheme started in 1993 with over 30 practices providing a specified data set quarterly via practice-generated tabulations, which were then re-keyed into spreadsheets at the health authority. The original data set included asthma, chronic bronchitis, cancer, cerebrovascular disease, diabetes, hypertension, hypothyroidism, ischaemic heart disease, alcohol, tobacco, blood pressure, body mass index, and disability indicators for over-75s. Some changes were made after the first year, and more emphasis was placed on improving the quality of the data. Ad hoc collections via MIQUEST were also used, (for example) to support investigations into an apparent epidemic of asthma, the effectiveness of interventions for gastro-intestinal conditions, and an audit of hypertension.

Feedback reports were provided to each practice in tabular and graphical form showing the practice relative to all others for each data category. For various reasons, the project was in abeyance for a while, but is now being re-activated, partly as a CHDGP pilot and partly to provide information to inform health needs assessment and commissioning on a locality basis.

Somerset

The Somerset project has been running for three years and is based on a sample of 12 practices selected to be representative of the county, both in terms of practice types and patient population. A large Total Purchasing Pilot is now also involved. Participating practices undertake to record at all consultations, including ‘episode types’ for the calculation of incidence and prevalence. It has been shown that regular data collection and feedback of results, coupled with in-practice checks of data quality and completeness, provide strong incentives to maintain good quality data. Routine outputs include tables of incidence and prevalence by age/sex for high cost or high volume conditions, with trends over time. The project also produces a quarterly review and an annual report. Each review includes an update on selected conditions and reports on three or four topics in greater depth. In the past the project has reported on incidence, prevalence, inter-practice variation, and comparisons with national data, on allergic rhinitis, angina, asthma, back disorders, depression, diabetes, glue ear, hypertension, infertility, non-organic psychotic mental illness, stroke and tonsillitis/ pharyngitis. There are various documented examples of practical uses in commissioning and contracting of information derived from the project, and the practices have used the comparative data to inform clinical audit.

Wirral

The CHDGP project has been built upon an existing project to develop locality sensitive planning based on accurate and timely morbidity and lifestyle data from primary care. Five ‘Practice Data Analysts’ work in sentinel practices, one per locality, and are also available to help other practices in the locality. Project work has already been undertaken into diabetes, aspirin for angina patients, surgical discharges, lipid lowering drugs, heliobacter pylori, and care provision to patients with severe enduring mental illness. For CHDGP the number of participating practices has been increased to two per locality. Future areas of focus are expected to include back pain, ACE inhibitors, and anxiety and depression.

Training and Support Team

The contract for the provision of training and support services for the Pilot Stage has been awarded to the Department of General Practice, University of Nottingham. By early 1998 the full team of three full-time employees plus part-time medical advisers and technical support staff, will be in place.

The team is contracted to provide advice, training and support as required to facilitators in all aspects of running a scheme in accordance with CHDGP principles. Priority will have to be given to the official pilot sites, but the team has sufficient capacity during 1998 to provide detailed assistance to at least another ten substantial schemes.

They are also responsible for developing and maintaining key project documentation including the Guidelines, training materials, libraries of MIQUEST queries, etc.

Comparative Analysis Service

The contract to provide this service for the duration of the Pilot Stage has also been awarded to the Department of General Practice, University of Nottingham. The core team on training and support are also involved with this contract, augmented by a data analyst and system development staff.

Data will be received quarterly via local scheme facilitators from practices that have achieved minimum data quality standards (and have agreed to have their data included in comparative reports beyond their local scheme). It will be validated and then analysed to produce a range of reports, as agreed with the users. Initially reports will focus on the core data set, but aggregate data on other conditions, and ad hoc reports based on linked health event datasets, can be produced in later cycles. All this will be done in close liaison with local scheme facilitators.

All data will be anonymised, and the team will ensure that patient and practice confidentiality is safeguarded, by exercising strict controls over access to the database, and by taking care over the level of aggregation in analyses, and the content of published reports.

User Representative Group

A User Representative Group has been established to provide feedback to the project team and to review and approve any changes to procedures or guidelines, and the specification and modus operandi of the comparative analysis service. Currently the Group has been selected from pilot schemes, but can be extended in future as the numbers and types of participants grow.