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Hunter of new QOF targets emerges from the shadows

Considering his role is so crucial to the future of general practice, it may seem odd that Dr Colin Hunter operates under the radar of most of his GP colleagues.

By Lilian Anekwe

Considering his role is so crucial to the future of general practice, it may seem odd that Dr Colin Hunter operates under the radar of most of his GP colleagues.

But the release of the changes to QOF under his chairmanship of the new NICE QOF advisory committee means he won't go unnoticed for much longer.

The GPC and many grassroots GPs were united in their disapproval of the Department of Health's decision to hand control of the QOF over to NICE: the institute didn't know enough about primary care, the timescale was too rushed, GPs' voices would be drowned out by secondary care experts and pressure groups – the list of reasons to be suspicious seemed to go on and on.

But three months since being appointed Dr Hunter and his colleagues have been quietly starting to reshape the QOF.

His credentials are sound: Dr Hunter, a GP in Aberdeen, was one of the GP academics who signed off the original QOF. But even as strong a candidate for the job as Dr Hunter admits the task has been fraught with challenges.

The first was sifting through the evidence to find new indicators for the GPC to negotiate on. In the end, the committee decided on an indicator for recording thyroid stimulating hormone in patients with learning disabilities, conception advice for women with epilepsy, plus two new blood pressure thresholds for patients with diabetes, 150/90 and 140/80mmHg.

Dr Hunter is confident they will be met with approval from GPs. ‘I don't think anyone will particularly disagree with the evidence base. They all sit within parts of the framework so there are no additional disease areas to negotiate. I suspect a great number of GPs will be doing this work already but not recording it in a way that makes it identifiable.

‘140/80mm Hg is a much more strenuous target. People will look at it and think "bloody hell, that's hard" but it depends where the thresholds are set.'

But setting thresholds is something in which the committee decided it would be best not to meddle.

‘It wasn't in our original remit but the DH subsequently asked us to take a look at thresholds and it became apparent during the discussions that it should be part of negotiation.

‘If you move thresholds up a number of practices will fall below the level. As soon as that happens, the judgement about how many practices therefore lose income becomes very clearly an issue for negotiation.'

An area where it was impossible for the committee to have remained as diplomatic is in trying to manifest the Department of Health's pledge to ramp up the number of outcome measures in the QOF.

But ultimately, Dr Hunter says the fine words of the politicians and pressure groups ultimately amounted to little when it came to concrete, evidence-based examples.

‘Both the epilepsy and the learning disability indicators are process indicators. The blood pressure indicator is an outcome measure in a sense. But to be honest the DH and those who responded to the consultation weren't able to provide any examples of good outcome measures in primary care.

‘The traditional outcome measures that centre around morbidity and mortality will not work in the QOF because you would need to measure them over a very long time. Saying "we want cardiovascular outcome measures" is great but you're never going to be able to apply that in practice. I don't think we will put any into the next stage of piloting, either.'

Although there may not be enough evidence to bring outcome measures in, that didn't stop the committee from recommending other indicators be potentially ruled out – including recording of HbA1c, cholesterol, blood pressure and eGFR.

‘There are some that exist in pairs of process indicators and outcome indicators, for example there's an indicator that talks about the measurement of blood pressure, and then an indicator that talks about getting blood pressure to a certain level.

‘Now, it could be argued that there's a little bit of double counting, because you can only achieve the second if you've done the first.

‘It's a no-brainer. You don't need an evidence base to say, actually there's an element of duplication. If almost every practice is doing it at the moment anyway then there could be an argument to take that indicator out.'

Contentious stuff, given the QOF was founded to drive up quality on the principle of ‘no new work without new money'. Dr Hunter concedes this new, maverick idea may not be received well – and indeed, may be rejected out of hand by the GPC.

‘All we have done is review the evidence. What the negotiators then do with that is a matter for them.' Though he hopes: ‘They may choose to move some of the measurements into actual target levels and move some points over, making points available for new indicators.... But all of that is the negotiators' job, not ours.'

But he does admit the effect of retiring indicators on performance will need close monitoring, whatever is decided. ‘It's actually quite difficult to know what will happen when you take indicators out of the framework – will recording go down? Will care for patients suffer? That's why the independent committee said anything that comes out needs to be monitored very carefully.'

‘We did see evidence of an effect when the smoking indicator was taken out of the asthma domain in the last QOF iteration, and certainly recording has reduced. So there's some effect already apparent. That did make us feel quite strongly that we should monitor any changes very closely.'

Dr Hunter seems to be balancing his roles of practising GP, public health advocate and policy shaper well so far. But given the noises being made by the present Government, and whoever may form the next Government, about buzzwords like patient outcomes, access and value for money, he acknowledges he will have to play an increasingly political role in order to mould the QOF to reflect ‘NHS priorities'.

Though he insists the committee will not be swayed by public demand.

‘If it wasn't an NHS priority but we consider it to be important to patient care, then in the mix of things, being important to patient care would probably outweigh it. Access is an NHS priority but as far as I'm aware continuity of care isn't. But these sorts of issues currently fall out of our remit, and into the organisational domain.'

And if a Conservative government were to shake up the remit of the committee, and the QOF, to reflect patient satisfaction? ‘If we were asked to look at patient feedback or the organisational ones I'm sure we'd be happy to do that and we'd apply the same criteria and processes.'

Dr Hunter and the rest of the QOF advisory committee will be cranking up their output in the coming months; ‘getting into step' by piloting 13 new indicators in practices from this October for inclusion in a 2011/12 QOF, and in December seeking suggested indicators for piloting for 2012/13. He and his committee's mission is to turn the QOF into a streamlined, efficient machine.

But whatever its efficiency, questions remain over what effect removing indicators will have on clinical care - and whether it really will be he 'no brainer' Dr Hunter believes it to be.

Dr Hunter on...

Retiring some indicators
'If almost every practice is doing it anyway there's an argument to take it out'

The tighter diabetes BP target
'People may think "blood hell, that's hard" but it dependes on where the thresholds are set'

Calls for 'hard' outcome measures in the QOF
'Saying you want cardiovascular outcome measures is great but you're never going to be able to apply that in practice'

The DH's request to look at thresholds
'Judging how many practices lose income is clearly an issue for negotiators'

Smoking indicators
'You record smoking at age 30-40, and also in CHD, so a patients aged 30-40 could have two bites of the cherry. We need to review smoking across the framework.'

Dr Colin Hunter: CV

- GP in Aberdeen for 23 years
- A former chair of the RCGPs' Scottish council, he is not honorary secretary of the RCGP and spends two days a week in London overseeing the CSA part of the nMRCGP examination
- He was involved in thrashing out the original QOF in the 2003/4 GMS contract talks
- NICE appointed him chair of the QOF indicator advisory committee in June, to develop and review indicators before making recommendations
- Dr Hunter also rund indicator pilots to assess their success before advising negotiators

Dr Colin Hunter: Role will become increasingly political as public priorities are balanced against clinical evidence Dr Colin Hunter

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