Data published for the first time today by HSJ reveals the GPs who exclude the most patients from their quality incentive scheme.

The£1.1bn quality and outcomes framework has long been dogged by suspicion that it is susceptible to manipulation and “gaming”. Practices can earn bonus payments for meeting targets relating to the treatment of patients with certain diseases. But they are able to discount - or “except” - certain patients when measuring their achievement against the target. Today, HSJ publishes on hsj.co.uk the details of exception reporting rates for all GP practices paid under the framework.

HSJ examined the 2006-07 exception reporting rate of 8,331 GP practices across 31 indicators in the framework, relating to the three priority disease groups of coronary heart disease, chronic obstructive pulmonary disease and diabetes.

The average exception rate across all the indicators was 7.4 per cent. But 168 practices had rates that were twice as high or more and nine practices had rates three times as high. This was after practices that had undergone large expansions or had small lists were removed.

For individual indicators, the range in exception rates is even greater. For one relatively simple indicator, which involves measuring a patient’s blood pressure once in 15 months, the average practice excepted just one patient in 100. But 122 practices excepted at a rate at least five times as high, while 20 excepted at 10 times the average rate or higher.

A senior source at the Department of Health told HSJ: “The variation is not acceptable. We believe some of these patients are simply being written off.”

Audit Commission managing director, health, Andy McKeon said those with very high rates raised “a genuine audit question”, as it meant practices were potentially being paid more than they were entitled to under the QOF. “We need to know what the PCTs are doing to review that,” he said.

PCT Network director David Stout said high exception rates could affect care. “We have to be careful we don’t consign a whole bundle of patients outside the system. You can except because the patient has decided not to comply, but does that mean you just stop trying?” he asked.

There are strict rules agreed by the DH and British Medical Association for exception reporting. But last month the National Audit Office said almost half of PCTs believed their processes for checking those rules were followed were not robust.

A spokesman for the DH said: “Any system may be open to gaming or manipulation. While there are processes - QOF assessment, pre-payment verification and [other] checks - there are opportunities for practices to inappropriately exception report patients. We believe most practices give good care and it is up to PCTs to ensure care is delivered.” He added that the current arrangements needed to be reformed, but this would only happen after discussion with the BMA.

Laurence Buckman, chairman of the BMA’s GPs committee, said: “Gaming is a really offensive term. It’s the same as calling someone a cheat or a crook. These are a very tiny number who are usually very easily identified because people who are bad doctors are bad crooks.”

Dr Buckman said GPs with nothing to hide should not fear their rates being published, as there were many legitimate reasons why a practice may have above average exception rates. At 13.1 per cent, his own practice had an exception rate 77 per cent higher than the national average, but he was confident this was justified. He said his Barnet practice caters for a large number of very elderly patients with dementia or who are on maximum dosages and treatment combinations.

A high rate could be due to a data entry error or a practice simply not understanding the system, he said.

HSJ contacted the 15 practices with the highest rates. There is no evidence they are gaming. The most common reason given for their exceptions was that patients had systematically failed, or refused, to attend the surgery for a review, despite receiving repeated invitations.

One practice partner said: “We have a major problem with these foreign patients because basically they don’t come for appointments or take their medication. They tell you salt is blessing, but salt is dangerous and to change their habits is difficult.”

How do the PCTs explain their rates?

Alongside the details of more than 8,000 GPs, HSJ today publishes the exception reporting rate for each primary care trust, the public bodies charged with managing GP contracts and performance.

The PCT with the highest exception reporting rate for the three disease groups examined - diabetes, heart disease and chronic obstructive pulmonary disease - is Barking and Dagenham. At 10.5 per cent, its rate is more than twice that of Harrow - the PCT with the lowest rate.

Barking and Dagenham head of GP contracting Colin Alderman told HSJ: “We are concerned at the overall levels and we have identified a number of practices with high levels we think warrant a review.” He said the issue was “right at the top” of the PCT’s priorities.

Caroline Taylor, chief executive of Croydon PCT, which has the second highest rate, was confident “the vast majority” of exceptions in her area were legitimate. She stressed that exception reporting “should not be seen as a bad thing”, as it removed an incentive for GPs to treat patients inappropriately.

PCTs and academics have often supposed there is a link between deprivation and high exceptions. But Dr Tim Doran of the National Primary Care Research and Development Centre said only up to 3 per cent of variation between GP practices could be explained by deprivation and other factors such as patient age and ethnicity. For example, Tower Hamlets PCT, the third most deprived PCT area according to the 2007 Index of Multiple Deprivation, has exception rates that are below average.

Its commissioning director, Andrew Ridley, said the PCT had a policy of conducting targeted visits to practices with the highest exception rates. It was also pushing practices to go beyond posting letters to invite patients for a review. Instead practices were using text messages and making telephone calls direct to patients in their own language.

Julie Taylor, head of contracts at Harrow PCT, which has the lowest rate of exception reporting, said the PCT pursued any outliers vigorously.

For more analysis, read this week’s leader.

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