Rewrite 2014 QOF indicators or risk GPs gaming system, NICE advisers warn NHS England
NICE’s QOF advisory committee has called on NHS England to reword some of the indicators which will remain in the shrunken 2014 QOF, in order to remove the potential for GPs to game the system.
The QOF advisory committee, which met in Manchester on Friday to discuss future recommendations for the framework, warned that the value of process checks in smoking and atrial fibrillation depend on doing other initial checks - checks which will no longer be incentivised as a result of the new GP contract deal.
The committee suggested that NHS England should reword the indicators which remain in each area in order to remedy the situation - even though committee members admitted doing so would mean effectively reinstating the removed indicators.
The comments from the advisory group come as it met for the first time since NHS England and the GPC negotiated wide-ranging changes to the QOF, including the retirement of 24 indicators worth a total of 185 points from the clinical domain and 14 indicators worth 33 points from the public health domain.
Asked to comment on the changes, advisers on the committee identified certain indicators which they argued had been skewed by the removal of other targets.
They said the removal of AF002 - assessment of stroke risk using the CHADS2 risk score in patients with atrial fibrillation - could affect the value of AF003 and AF004, which assess the proportion of patients who are treated appropriately based on their CHADS2 score.
The committee had previously warned that the removal of AF002 could introduce ‘selection bias’, whereby practices ‘could be rewarded for all three indicators for only undertaking the CHADS2 score on a subset of people with AF’.
At Friday’s meeting committee members said that to get round this, the remaining indicators could be changed so that practices are judged on how many people they assess in the first place and then treat if needed.
Similarly, the removal of SMOK001 from next April - making sure all patients aged 15 or over are asked whether they smoke and put on the smoking register if they do - means SMOK004 should be reworded to require all patients are still asked about smoking and then offered smoking cessation if needed, the advisory group said.
NICE reporting restrictions forbid Pulse from directly quoting the committee’s discussion, even though it was held in public. A nine-page document setting out guidelines for observers at the committee meeting instructs journalists that ‘you may not quote committee members directly unless NICE provides explicit approval and the committee member has agreed to be quoted’ and insists ‘any direct quotations for external publication are limited to the final summary’.
However the potential for GPs to game the 2014 QOF was repeatedly remarked upon by committee members, and there was widespread support for indicators in the QOF to be rewritten even though it was acknowledged that this would effectively mean the covert reinstatement of indicators which were supposed to have been axed.
The comments from the committee add weight to the argument of those GPs who believe the impact of QOF changes will be limited in terms of GP workload - given NHS England’s stated aim to continue monitoring retired process indicators in other ways. At the NICE meeting, an NHS England representative reassured the QOF advisory committee that performance on the removed indicators would continue to be monitored, with the results used in particular to inform the new CQC inspection regime under the chief inspector of general practice, Professor Steve Field.
The committee also expressed concerns about how decisions on retiring QOF indicators had been made without any explanation forthcoming from NHS England, with some members particularly alarmed by the removal of the mental health indicators without apparent consideration of the impact on outcomes, as highlighted to Pulse by GP specialists in mental health.
NHS England moved to reassure QOF advisers their input would be needed in future, and an urgent meeting has been called between NHS England clinical leads and senior NICE staff for early 2014, to start planning the future direction of QOF beyond 2014/2015.
Dr Colin Hunter, chair of the advisory committee, said despite the committee members’ concerns about the way indicators had been being taken out this had always been the nature of negotiations.
He said: ‘I don’t think any of us disagree with the need to reduce the QOF and redirect funding into core funding of general practice.
‘Perhaps because of the nature of the negotiations the rationale is unclear about how these decisions have been arrived at. But maybe that is something we have to accept. Certainly throughout my involvement in advising on the QOF, we have have to recognise that negotiations are confidential and complex.’
He added that in future NICE would need much greater clarity for the criteria for inclusion and exclusion of indicators.
He said: ‘I have a sense we’re on two parallel roads that are diverging, so that NHS England and we get to two completely different places and that’s not helpful for either party.’
‘We will need to have discussions over the next few months to clarify what our role is.’