Ann Shaw, PRIMIS+ facilitator at Amber Valley PCT (*now amalgamated into Derby County PCT), has been improving patient care and helping practices meet the requirements of the new GMS Contract by focusing on Chronic Disease Registers.

The new GMS Contract requires practices to keep a register of patients who fit within any of the ten chronic disease areas to ensure that the appropriate care pathway is followed for each patient. In turn, practices receive points for the number of patients on the register, and for the number of those who are given predefined treatments or care within a specific timescale. To receive the maximum points available, data must be validated and correct. Having a fully validated disease register allows a practice to offer optimum services for patients: patients who are diagnosed and added to the register are more likely to receive appropriate and timely care.

Ann has worked with practices to improve the way Chronic Disease Registers are managed. She has organised workshops for GPs and practice staff to discuss the new GMS Contract requirements and agree standards of data coding across the PCT. She has arranged notes summarising training for lead GPs and other staff to promote accurate and relevant clinical summaries. In her role as a facilitator, she has shared best practice and worked to establish a link between the achievement of the new Contract's requirements and the delivery of better patient care.

As a result, improvements in the level of recording of chronic disease diagnosis have been made across the PCT, along with improvements in the recording of correct diagnosis codes. Patients who do not attend their reviews can be identified and recalled easily. Staff save time by searching electronically for patients within the registers. All practices are now producing meaningful Chronic Disease Registers, and this reflects the positive way in which GPs and practice staff have responded to the new challenges of the GMS contract, with the support and facilitation Ann has provided.

* Since this case study was first produced, Amber Valley was amalgamated into Derby County PCT, following the 2006 PCT restructuring.