Best Practice: advice for using quality indicators to improve the care of children

The care of children is an important part of general practice. However, only 3% of Quality Outcomes Framework (QOF) markers in general practice relate to children and there is not a set of child-relevant indicators that can be implemented in UK primary care. Dr Peter Gill, with a passion for child health care in general practice, developed a set of quality indicators to improve patient care for children1. In the interview below Peter Gill provides advice for general practice on the use of quality indicators to support children.


What is your top advice for GPs about using quality indicators to support the care of children?

  • Quality indicators can be used to measure and improve quality of care.
  • With the guidance of a group of GPs we developed a set of quality indicators relevant to the care of children and adolescents.
  • Examples of indicators which are easily audited from computer GP records include:
    • Children and young people admitted or seen in secondary care for an asthma exacerbation should be assessed within 30 days in primary care.
    • Antibiotic prescriptions in children should be accompanied by a clearly documented rationale for this decision.
    • Children with a first non-febrile seizure should have clearly documented evidence of referral to secondary care for further assessment.
    • Children taking methylphenidate, atomoxetine, or dexamfetamine should have clearly documented monitoring.
    • Children about whom a practitioner suspects neglect or abuse should have evidence that a clear and recorded course of action was taken.
    • 'Looked-after' children and young people should be clearly identified in the GP's summary record.

Why was it important for you to develop quality indicators for children?

The care of children plays an important role in UK general practice. In 2009, almost 11% of GP consultations were for children under the age of 16. Yet there is evidence from unplanned hospital admissions and preventable deaths that care quality can be improved. Despite the importance of child health, few of the financially incentivised indicators in the QOF are child specific. Several large studies evaluating the impact of QOF in UK general practice suggest that omission from the framework probably has a negative impact on care quality. While the amount of funding allocated to QOF is decreasing, the use of markers for audit and governance is not diminishing. Quality indicators, defined as measurable aspects of care against which quality standards can be set and audited, have been developed and implemented from some aspects of child primary care in certain countries. However, obvious gaps remain. We sought to develop a set of quality indicators for the primary care of children and adolescents which include a wide range of paediatric care and reflect existing evidence-based national guidelines.

What does your work say that is new for general practice?

We developed a set of quality indicators for clinical areas agreed to be of importance to high quality primary care for children and adolescents. We used a detailed multi-step development process which included selecting priority areas, reviewing NICE and SIGN national guidelines relevant to children in primary care, and translating guideline recommendations into quality indicators. A UK-wide panel of GPs with a special interest in child health assessed the validity and implementation of indicators using the RAND methodology, A widely-used methodology to generate professional consensus. The 35 indicators have high levels of clinical support, reflect national guidelines, and could be feasibly implemented in the UK by audit of computerised general practice records.

While there are proposed UK indicators for child and adolescent mental health and other diseases-specific areas, we provide the first set which is designed for routine monitoring and quality assurance. There is some overlap between our work and the quality standards which NICE are starting to publish (e.g. epilepsy), but we address broader determinants of child health outside of clinical guidelines such as focusing on child safeguarding and professional development. Other indicators prompt GPs to critically reflect on their actions (e.g. rationale for antibiotic prescribing), taking into account individual patient concerns.

How can patients benefit from your work?

The quality indicators have not yet been piloted or implemented in UK general practice. However, there are many ways in which the care quality can improve with implementation of the indicators. For example, the indicators may lead to the earlier diagnosis of easily missed conditions such as Coeliac disease and Type 1 Diabetes which may improve quality of life and reduce complications. In 2008, there were 6300 paediatric medication related safety incidents; the prescribing indicators may improve medication safety. Appropriate evidence-based management of common conditions such as asthma, may reduce emergency department visits and secondary care referral. Each indicator, after appropriate piloting in general practice, could potentially play an important role to improve care quality and identify which areas require increased attention.

How has this research helped you as a clinician?

Conducting research has significantly changed how I practice medicine. After completing four years of full-time research in Oxford and returning to post-graduate clinical training in paediatrics in Canada, I have a thorough understanding of clinical medicine and research. There are many unanswered questions, and by having the opportunity to conduct research in a world-leading institution, I have developed a skill set that will help solidify a career focused on clinical care and research. Pursuing these aims will ultimately make me a better clinician and improve patient care.

I am grateful to the RCGP Scientific Foundation Board for providing funding to complete this important project which formed an essential part of my doctoral thesis. This unique research fund provided for junior researchers plays a pivotal role in fostering a new generation of primary care clinician scientists. It has been a worthwhile journey, from completing my first ever grant application in 2010 to winning the 2013 Dr Barbara Starfield Award at the North American Primary Care Research Group Conference for the best completed research project by a trainee.

Do you have any further messages for GPs, commissioners or policy makers?

With the on-going re-structuring of the NHS, care quality for children and adolescents should not be ignored. It is important that quality indicators, whether linked to QOF payment-by-results or used as an audit tool for clinical governance, cover the full range of UK general practice. The indicator set we have developed reflects both professional concerns and existing primary care records. In the US, primary care indicators not only improved care but were signed into law by President Obama in 2009 through the Children's Health Insurance Program Reauthorisation Act. Bolder steps are needed to implement paediatric indicators in UK primary care.

[1] Peter J Gill, Braden O'Neill, Peter Rose, David Mant and Anthony Harden. Primary care quality indicators for children: measuring quality in UK general practice. British Journal of General Practice. 2014; 64(629):e752-e757

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