1. health and fitness

How to develop a taxonomy
of general medical practices
to support and encourage
performance development
Health Inequalities
National Support Team
Enhanced Support Programme
3
DH INFORMATION READER BOX
Policy
HR/Workforce
Management
Planning/Performance
Clinical
Estates
Commissioning
IM&T
Finance
Social Care/Partnership Working
Document purpose
Best Practice Guidance
Gateway reference
13582
Title
How to Develop a Taxonomy of General Medical Practices to Support and
Encourage Performance Development
Author
Peter Counsell
Publication date
05 Mar 2010
Target audience
PCT CEs, NHS Trust CEs, Care Trusts CEs, Foundation Trust CEs, Directors
of PH, Local Authority CEs
Circulation list
SHA CEs, Medical Directors, Directors of Nursing, Directors of Adult SSs,
PCT PEC Chairs, PCT Chairs, NHS Trust Board Chairs, Special HA CEs,
Directors of HR, Directors of Finance, Allied Health Professionals, GPs,
Communications Leads, Emergency Care Leads, Directors of Children’s SSs,
Voluntary Organisations/NDPBs
Description
One in a series of “How to” guides published as part of the Redoubling efforts
to achieve the 2010 National Health Inequalities Life Expectancy Target
resource pack
Cross ref
Systematically Addressing Health Inequalities
Superseded docs
N/A
Action required
N/A
Timing
N/A
Contact details
Health Inequalities National Support Team
National Support Team (NSTs)
Wellington House
133-155 Waterloo Road
London SE1 8UG
0207 972 3377
www.dh.gov.uk/hinst
For recipient’s use
HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
Population focus
Population health
10. Supported self­
management
Systematic
community
engagement
(C)
Systematic and scaled
interventions by
frontline services
(B)
9. Responsive services
Optimal
population
outcome
Challenge to providers
13. Networks, leadership
and co­ordination
6. Known
population
needs
8. Equitable resourcing
Personal
health
Frontline service engagement
with the community (D)
Community
health
4. Accessibility
2. Local service
effectiveness
7. Expressed demand
Partnership,
vision and strategy, leadership and engagement
(A)
5. Engaging the public
12. Balanced service portfolio
11. Adequate service volumes
1. Known
intervention
efficacy
3. Cost­effectiveness
Bentley C (2007). Systematically Addressing Health Inequalities, Health Inequalities National Support Team.
Foreword
TheHealthInequalitiesNationalSupportTeam(HINST)haschosentoprioritisethistopic
asoneofits‘Howto’guidesforthefollowingreasons:
• Itoffersthepotentialtosystematicallyimprovetheoutcomesfromevidence-based
treatmentofpatientswithpotentially‘killer’conditions,onascalethatcouldenable
theindividualpatientqualityimprovementstoadduptoapopulation-levelchange.
• Specificallywithinthe‘Christmastree’diagnosticitaddressesthefollowingcomponents:
– Localserviceeffectiveness(2).Clusteringofpracticeslikewithlikeinrelationtothe
characteristicsofthepracticepopulationallowspracticeperformanceonservice
outcomestobebenchmarkedappropriately,enablestheidentificationof‘cluster
champions’,allowspracticessharingthesamecontexttoexchangeexperienceon
whatworksandwhatdoesn’t,andenablestheprimarycaretrust(PCT)toprovide
differentialinputstopracticesbasedontheirdemography.
• AdoptionofthesuggestedclusteringofpracticesshouldhelpmeettheQualityand
ProductivityChallengebyprovidingpracticeswithbenchmarkoutcomesachieved
byotherswithasimilarpracticeprofile,andsohelpingto‘raisethebar’onwhatis
realisticallypossible.
• Successfuladoptionofprocessessimilartothoseoutlinedherewoulddemonstrate
gooduseofWorldClassCommissioning(WCC)Competencies:
– Clinicalleadership(4)
– Stimulatesprovision(7)
– Innovation(8)
– Performancemanagement(10).
1
HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
CoNTexT
Thisguideprovidesexamplesofhowtheprocesshasbeenundertakensuccessfullyand
recommendsstepstocreatingagroupingorTaxonomyofPractices.Thisguideneedsto
readalongsideHow to develop and implement a balanced scorecard.
STePS To deVeLoP A TAxoNoMY oF PrACTICeS
TheDepartmentofHealthhascirculatedthePrimaryCareCommissioningSupport
ApplicationproducedbythePrimaryCareCommissioningTeam.Thisapplicationtool
allowscomparisonsbetweenPCTsandbetweenpracticesbasedonseveralsocio-economic
indicatorsthatarealreadyavailableinthisapplication.ItissuggestedthatPCTsuse
thistoolasthebasistorankpracticesbytheirIndexofMultipleDeprivation(IMD)and
combinethiswithananalysisofdemographicfactors.Thiswillenablesegmentation.
PCTsshouldconsiderinvolvingtheirequalityanddiversityleadstoexplorehowthistool
canbelocalised,incorporatingotherequalitydimensions,nationalequalityguidanceand
localequalitypolicies.
Step 1
UsingthePrimaryCareCommissioningSupportApplication,rankpracticesaccording
totheIMD2007score.
Figure1isasimpledemonstrationofhowpracticescanbegroupedtogetherbasedon
theIMD.Thisallowscomparisonofresultstobemadebetweentruepeers:practicesthat
shareasimilarpopulationbasedontheirIMDscores.
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HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
Figure 1: Indicator table – GP practice level
back to main menu
Please select your PCT:
Select a GP practice to compare it against 40 most
similar practices in England, as measured by IMD:
Select indicator category:
Please select an Indicator:
Rank
1
2
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4
5
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8
9
10
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12
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14
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16
17
18
19
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21
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Code
P82641
P82625
P82640
P82642
P82633
P82629
P82013
P82657
P82617
Y00186
P82004
P82626
P82609
P82037
P82616
P82029
P82008
P82660
P82030
P82652
P82002
P82012
P82628
P82018
P82033
Y00199
P82022
P82624
P82009
P82011
P82634
P82019
P82010
P82001
P82020
P82007
P82627
P82025
P82607
P82613
P82036
P82631
P82006
P82016
P82014
P82615
P82637
P82031
P82015
P82003
P82005
P82650
P82021
P82023
P82034
P82643
Bolton
All practices within PCT
Top 10%:
43.1
Bottom 25%:
21.2
Top 25%:
39.6
Bottom 10%:
18.1
Median:
31.9
Aspiration:
0
(56 peer practices in PCT)
Needs ­ Socioeconomics
IMD
Data source:
The index of multiple deprivation derived from seven “domains” of deprivation (income, employment, health deprivation and disability,
education, skills and training, barriers to housing and services, crime and disorder and living environment) (The Office for National Statistics).
0
10
20
30
40
50
GP practice
PCT
Value
The Derby Practice
Bolton
48.5
Charlotte Street Surgery
Bolton
48.1
Pikes Lane 3
Bolton
46.1
Great Lever Health Centre 2
Bolton
44.0
Great Lever Health Centre 1
Bolton
43.1
Pikes Lane 2
Bolton
43.0
Lever Chambers 2
Bolton
42.0
Greenland Road
Bolton
41.8
Astley Brook Surgery
Bolton
41.6
3D Medical Centre
Bolton
41.2
Swan Lane Medical Centre
Bolton
40.4
Halliwell Surgery 3
Bolton
40.3
Shanti Medical Centre
Bolton
40.0
Farnworth Health Centre 1
Bolton
39.6
Crescent Road Surgery
Bolton
39.6
Halliwell Surgery 2
Bolton
39.0
Stonehill Medical Centre
Bolton
38.6
Deane Clinic 1
Bolton
38.4
Deane Medical Centre
Bolton
37.6
Farnworth Health Centre 2
Bolton
37.3
Pikes Lane 1
Bolton
37.0
Lever Chambers 1
Bolton
36.8
Bolton Road Surgery
Bolton
36.8
Alastair Ross Health Centre 1
Bolton
34.9
Bradford Street Surgery
Bolton
34.7
Avondale Health Centre 3
Bolton
34.1
Halliwell Surgery 1
Bolton
32.9
Laxmi Medical Centre
Bolton
31.9
St Helens Road Practice
Bolton
31.0
Tonge Fold Health Centre
Bolton
30.9
Wyresdale Road Surgery
Bolton
30.8
Alastair Ross Health Centre 2
Bolton
30.1
Avondale Health Centre 1
Bolton
29.9
Dunstan Medical Centre
Bolton
29.1
Little Lever Health Centre 1
Bolton
28.6
Kearsley Medical Centre
Bolton
27.9
Cornerstone Surgery
Bolton
25.4
Burnside Surgery
Bolton
24.7
Crompton Health Centre
Bolton
22.8
Spring View Medical Centre
Bolton
22.5
Little Lever Health Centre 2
Bolton
21.7
Little Lever Health Centre 3
Bolton
21.2
Pike View Medical Centre
Bolton
20.5
Harwood Health Centre
Bolton
20.2
Spring House Surgery
Bolton
19.9
Market Surgery
Bolton
19.8
Victoria Road Surgery
Bolton
19.7
Heaton Medical Centre
Bolton
19.1
Unsworth Group Practice
Bolton
18.4
Kildonan House
Bolton
18.3
Stable Fold Surgery
Bolton
18.1
Ladybridge Surgery
Bolton
16.3
Crompton Health Centre
Bolton
16.0
12.1
Mandalay Medical Centre
Bolton
Edgworth Medical Centre
Bolton
10.4
Egerton/Dunscar Health Centre
Bolton
9.2
60
back to PCT profile
view PCT indicator table
Top 25%
Median
Aspiration
Thetoolalsoenablescomparisonsofperformancetobemadebetweenpracticeswith
similarcharacteristicsfromdifferentPCTsacrossthecountry,butthisisnotpursuedhere.
Step 2
Determinetheadditionalsocio-demographicfactorsthataredeemedtohaveanimpact
onpracticeperformance,forexample:
a.Age–usingagevariablesforindividualsintheGPpatientregister.
b.Rurality–maybeafactorinsomeareas–particularlywhenintra-districtinequalities
arebeinglookedat.Thisandothervariablesareavailablefromthegeneralmedical
servicesglobalsumallocationsformula,includingonethatmaygiveaninsightintoa
phenomenonassociatedwithdifficultiesinaccessingservices:‘populationchurn’.
c.Practicelistturnoverindex.
YorkshireandHumberPublicHealthObservatoryhasdevelopedpracticeclustersnot
withinaPCTbutwithinaregion–usingthevariablesofage,sex,ethnicity,deprivation,
andurban/rural–usingtheNHSNationalStrategicTracingService.
3
HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
TheNHSNationalStrategicTracingServicecontainsadministrativedataonallpatients
registeredwiththeNHS.YorkshireandHumberPublicHealthObservatoryused
99.9%ofthesedatatobuilditsmodelandgrouppracticesintoclustersusingk-means
clusteranalysis.1
Ifeachofthefactorswerejudgedtohavethesameimportance,thentherewouldhave
tobesomeprocesstostandardisethescaleusedforeachvariableandtheirranking–to
avoiddisproportionateinfluence.HINSTrecommendsusingtheIMDscoreastheprimary
determinantofthecluster,andtouseonlyacoupleofadditionalfieldsthathaverelevance
andcredibilitylocallyinordertomoderatetheclusters.Atthisstagethereisnoevidence
thatsophisticationaddsvalue.
Step 3
Placepracticesinbandsandusecut-offpoints(e.g.quintiles)toformgroups;thenapply
localknowledgetojudgewhetheranypracticesstandoutasbeingincludedwithothers
thatareobviouslydifferent–the‘realitytest’.Formulateexplicitrulesthatexplainthe
adjustmentsthatareneededtomakethegroupingsobtainedpurelyfromthedatainto
sensiblegroups.
Step 4
Usetheresultssplitbypracticegroupstopopulateaperformancedatareportusing,for
example,QualityandOutcomesFramework(QOF)scores,takingaccountofthe‘How
to’guide.
How To USe THe TAxoNoMY oF PrACTICeS
TheTaxonomyofPracticescanbeusedbythePCTandpractice-basedcommissioning
groupstoidentifyopportunitiestoclustersimilarpracticesinrelationtothe
characteristicsofthepracticepopulationinorderto:
• allowpracticeperformanceonserviceoutcomestobebenchmarkedappropriately
• enabletheidentificationof‘clusterchampions’
• allowpracticessharingthesamecontexttoexchangeexperienceonwhatworksand
whatdoesn’t
• enablethePCTtoprovidedifferentinputstopracticesbasedontheirdemography.
NHSBoltondevelopedasetofGeneralPracticeclusters(‘TaxonomyofPractices’)to
enableacomparisonofperformancethattakesintoaccountthedifferentpopulations
thatpracticesworkwith.NHSOldhamhasdonethesameaspartofaninvestigationinto
thenumbersofpatientsondiseaseregisterscomparedwithpredictedprevalence.
4
HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
The NHS Bolton approach to grouping practices
Demographiccharacteristics
• Deprivation
• Ethnicity
• Age
+ Local
knowledge
Practice
‘taxonomy’
Threeaspectsofpopulationdatawereusedtosuggestinitialgroupingsbased
uponthedemographicprofileofpractices.
Group 1 – Deprivation
IMD2007scoresatLowerStandardOutputAreawereusedandthepostcodes
ofpatientsassignedtothem.Anoverallaveragedeprivationscorewascalculated
foreachpractice.
Group 2 – Ethnicity
Themajorityoftheblackandminorityethnic(BME)populationinBoltonis
ofSouthAsianorigin.TheNamPehchansurnamerecognitionsoftwarewas
usedtoidentifynamesofpossibleSouthAsianorigin.Thissoftwarehassome
limitationsbutuntilfullethniccodingforallpatientsisavailableitisconsidered
aworkabletoolwithahighlevelofspecificitybutonlywhentheminorityethnic
populationisofSouthAsianorigin.Thesoftwarewasusedtogrouppractices,
broadly,intohighBME,mixedandwhitegroupings.
Group 3 – Age
Originally,NHSBoltonusedanageindexscorethatwascalculatedusing
prescribingunitsdata,butitisnowrecommendedthattheaveragepopulation
ageiscalculatedforeachpracticeusingtheagevariableforindividualsinthe
GPpatientregister.
Thesethreecharacteristicswereusedtoidentifypracticegroups,butanelement
oflocalknowledgewasthenaddedtoensurethatobviousanomalieswere
addressed.Thisstepislesseasytodescribeinobjectiveterms,butalltoolslike
thisneedtoundergoa‘realitycheck’beforetheyareapplied.
ThePCThasusedthisinformationtoreportperformance(QOFbased)onkey
indicatorstothePCTBoardandisworkingonasetofmeasuresthatbetter
describethePCT’sprogresstowardsimplementingmajorprogrammesthat
willimprovehealthandreducethegapinlifeexpectancybetweenthedistrict
andtheaverageforEngland.Progressandneedforsupportwillbemonitored
throughamatrixshowingpractices,inthecontextofpracticeclusters.Itis
proposedthatthiswillbethesubjectofafurther‘Howto’guideinduecourse.
5
HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
The NHS Oldham approach to grouping practices
TheHINSTreportfollowingitsvisittoOldhamlastyearrecommendedthe
calculationofpredictedregistersizesatapracticelevel.
Calculationswereundertakentoestimatethepredictedpracticeregistersizes
relatingtovasculardisease,chronicobstructivepulmonarydisease(COPD)
andasthma.Anintegralpartoftheprocesswasthecreationofpracticegroups
basedonpracticepopulationsize,ethnicityanddeprivationlevel.
Thepractice population dataarebasedonJanuary2009Exeterdata,withthe
exceptionof:
• ExeterdataforNovember2009fortheasthmapredictions
• 2007listdatafortheCOPDpredictions(AssociationofPublicHealth
Observatoriescalculations).
Predictionshavenotbeenmadeforthenewpracticesastheydonotyethave
astablepopulationonwhichtobasetheprediction.
ToestimatetheproportionofthepracticepopulationfromBMe heritage,the
NamPehchansurnamerecognitionsoftwarewasusedtoidentifyregistered
patientsofSouthAsianorigin.
Thedeprivation levelofeachpracticehasbeenestimatedusingtheUV67
householddeprivationscore(seeTable1).UV67householddeprivationscores
werecalculatedforeachcensusoutputareainOldham,using2001census
data.GPpracticescoreswerethenestimatedbyusingthepostcodesofeach
patienttocalculatetheproportionofpatientsfallingwithinasuperoutputarea.
Thehigherthepercentagescore,themoredeprivedtheGPpracticepopulation.
Forexample,aGPpracticewithascoreof40%isclassedasverydeprived.
Table 1: Variables included in the UV67 household deprivation score
6
Employment
Anymemberofthehouseholdaged16to74whoisnota
full-timestudentoriseitherunemployedorpermanentlysick
Education
Nomemberofthehouseholdaged16topensionableage
hasatleastfiveGCSEs(A–C)orequivalent,andnomember
ofthehouseholdaged16–18isinfull-timeeducation
Health and
disability
Anymemberofthehouseholdhasageneralhealth‘not
good’intheyearbeforecensusorhasalimitinglong-term
illness/condition
HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
Table 1: Variables included in the UV67 household deprivation score
continued
Housing
Thehousehold’saccommodationiseitherovercrowded,
orisinashareddwelling,ordoesnothavesoleuseofa
bath/showerandatoilet,orhasnocentralheating
Thevariablesintable1wereusedfortheprimarypurposeoftheexercise–
comparingthenumberofpatientsonchronicdiseaseregistersagainstthe
predictedprevalenceratesforprimarycarepracticeregistersforvascular
disease,COPDandasthma.
reFereNCeS
1 Forclustercharacteristics:www.yhpho.org.uk/resource/view.aspx?RID=10390
Forthemethodology:www.yhpho.org.uk/resource/item.aspx?RID=10073Thisthen
enablespracticeprofilesona‘likeforlike’basis.Todownloadprofiles:www.yhpho.
org.uk/resource/view.aspx?RID=10319#
ThisfollowsworkbyEmmaMaundaspartofanMScinHealthServicesResearch,
UniversityofYork,in2008.
7
HowtodevelopaTaxonomyofGeneralMedicalPracticestosupport
andencourageperformancedevelopment
AUTHor ANd ACkNowLedgeMeNTS
Written by:
PeterCounsell,AssociateDeliveryManager
HealthInequalitiesNationalSupportTeam
hinst@dh.gsi.gov.uk
Acknowledgements:
CatherineJenkins,HeadofQualityTeam–PrimaryMedicalCareBranch
CommissioningandSystemManagementDirectorate
DepartmentofHealth
DavidHolt,HeadofPublicHealthIntelligence
NHSBolton
HemlataFletcher,EqualityandDiversityLead,TransformingCommunityServices
DepartmentofHealth
JacquiDorman,PublicHealthInformationManager
NHSOldham
JillMatthews,Director–PrimaryCareandCommunityServicesStrategy,and
PrimaryCareCommissioningandSystemManagement
DepartmentofHealth
DrLisaWilkins,ConsultantinPublicHealthMedicine
DepartmentofHealth
ZawarPatel,PolicyAdvisor–EqualityandInclusion
DepartmentofHealth
Ifyouwantmoreinformationontheexamplescontainedinthisguidepleasecontact
HINSTon02079723377oremailhinst@dh.gsi.gov.uk
8