KISS: Learning Disabilities QOF QI Domain 2020/21

KISS Header
Reference: NHSE Feb 2020

The indicator focusses on contractor engagement and participation in QI activity in the practice and through shared learning across the network. It is recognised that not all QI activity will be successful in terms of immediate impact on patient care, but measurable improvement in the quality of care is generally expected.

Indicators:
  • QILD007 - The contractor can demonstrate continuous quality improvement activity focused upon learning disabilities as specified in the QOF guidance.
  • QILD008 - The contractor has participated in network activity to regularly share and discuss learning from QI activity focused on the care of patients with a learning disability as specified in the QOF guidance. This would usually include participating in a minimum of 2 network peer review meetings.
Background:
  • A learning disability (LD) is a 'significantly reduced ability to understand complex information or learn new skills; a reduced ability to cope independently; and a condition which started before adulthood with a lasting effect'.
  • There is significant health inequality for people with LD:
    • Average age of death for people with LD is 23 years younger (male) and 27 years younger ( female); commonest causes of death are pneumonia, aspiration pneumonia, sepsis, dementia, CVD, epilepsy.
    • A confidential enquiry concluded that 42% of deaths for people with LD are premature, with the commonest reasons being delays to diagnosis and treatment, problems with identifying needs and providing appropriate care.
  • People with LD are more likely to have co-morbidities - most commonly obesity, asthma, constipation, dysphagia, GORD, epilepsy,  dementia, mental health problems.
  • People with LD are less likely to take up national screening programmes and have flu vaccinations.
  • There is considered to be significant over-prescribing of psychotropic drugs in people with LD, especially antipsychotics, which increases the risk of harm; data from PHE 2015 based on GP records showed <50% of people with LD being prescribed antipsychotics had a licensed indication recorded.
  • Currently only ~25% of the expected 1.1 million people with LD are recorded on the LD QOF register.
Overview of QI module - Main Aims:
  1. Improve the accuracy of the GP register by increasing the identification and coding of people with LD.
  2. Increase uptake of annual health checks.
  3. Optimisation of medications, with a focus on appropriate prescribing of antipsychotics. 
  4. Recording the need for reasonable adjustments required.
  5. Consider wider use of community support with local LD services and social prescribers.
What do practices need to do? 5 steps
  1. Identify areas for improvement by assessing the current quality of care:
    • Improve accuracy and increase prevalence of LD QOF register - NHSE has produced a useful document on improving identification of people with LD including a list of codes that do indicate a LD, codes that may indicate a LD and an 'inclusion tool' to help us identify who would benefit from being added to the register - click here.
    • Complete a whole practice training needs analysis in LD awareness.
    • Reflect on practice's overall approach to caring for people with LD e.g. rate of annual health check completion, cancer screening and vaccination rates, long term condition management.
    • Evaluate how reasonable adjustments are identified, highlighted and implemented. 
    • Consider involving the local community LD team, where possible, to provide support and advice on identifying areas for improvement. 
  2. Create an improvement plan:
    • Identify area(s) for improvement (see below box for examples to consider) based on diagnostic phase above, which should focus on:
      • Increasing number of people on LD register - for NHSE document to aid with this click here.
      • Increasing uptake of annual health checks aiming for national target of 75% of those on LD register (aged ≥ 14 years old); there is meta-analysis evidence that health checks for people with LD are effective in identifying previously unrecognised health needs, including life‐threatening conditions. There is further guidance and support on health checks from NICE (NG 54 2016) and the RCGP (LD toolkit on annual health checks).
      • One important aspect of the health check is a medication review - general practice has a key role in optimising prescribing to reduce harm, particularly the over-prescribing of psychotropic medications; see further information on the STOMP initiative which has lots of useful information including support and help for both health professionals and families/carers in managing challenging behaviour without medication from the Challenging Behaviour Foundation.
      • Increasing numbers of people with LD of all ages having annual flu immunisation - the commonest cause of death in people with LD is respiratory tract infection.
      • Improving provision and understanding of Reasonable Adjustments and use of the Flag - for further information on the Reasonable Adjustment Flag click here.
    • Practices should choose their own QI activities and set their own targets based on their baseline audits and search results; these should be challenging but realistic and validated by network peers as part of the initial network review meeting.
    • Make sure the aims are SMART (specific, measurable, achievable, relevant, time-bound).
    • Multiple small tests of change are recommended.
    • >Practices should aim to ensure improvement is continuous and QI becomes routine.
  3. Implement the plan:
    • It is recommended that the plan and activities involve the whole practice team and (where practicable) people outside the practice e.g. LD services, social prescribers, network pharmacists, patient/family/carer support groups.
  4. GP network peer review meetings:
    • A key objective is to enable shared learning across the network, especially around wider system issues that impact on the quality of care that require collective responses.
    • Contractors should participate in a minimum of 2 network peer review discussions (usually through the PCN) and a record of attendance maintained.
    • Network to decide the timing of meetings, but it is recommended that the first meeting takes place early to decide on QI activities, with the second towards the end to share outcomes and learning.
  5. Reporting and verification:
    • Complete the QI monitoring template - self-declare activity described has been completed and attendance at a minimum of 2 network review meetings.
    • Commissioners may require written evidence that QI activity has been undertaken and of attendance at the peer review meetings.

Examples of Quality Improvement Ideas (see full NHSE document for further examples) 

  • The practice last year completed annual health checks on X% of people >14 years old on QOF LD register - Aim to increase proportion to 75% within Y months.
  • The practice has no system for identifying and recording reasonable adjustments needed - Aim to introduce a system that leads to X% of all patients with LD having an agreed digital flag within 12 months.
  • The practice identified that X% of people on QOF LD register had a recorded flu vaccination last year - Aim to increase the proportion receiving the flu vaccination to Y% within 12 months. 
  • A patient on the LD register died during the preceding 12 months but no documented learning had taken place - Aim that every death of a person on the LD register is considered a significant event with documented reflective analysis on what lessons can be learned including identification of good practice and areas for improvement. 
Published on 12th August 2020

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