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NICE to reduce 'double-counting' with removal of QOF indicators

By Nigel Praities

NICE has released controversial plans to retire a series of QOF indicators to avoid ‘double-counting' and remove payments for areas of care it considers to be embedded into practice.

The BMA has warned the proposals could prove detrimental for patient care, as evidence emerged of a dip in performance after smoking indicators were removed.

The institute's QOF indicator advisory committee published a list of five indicators it considers suitable for retirement and another three that might be suitable.

Indicators earmarked for retirement include points for recording cholesterol, blood pressure and HbA1c in patients with diabetes and blood pressure in coronary heart disease, TIA and stroke.

The committee said removal of these indicators had a ‘low level of risk', since recording was also covered by target-based indicators.

Pulse first revealed as early as December last year that NICE intended to tackle double-counting of cardiovascular indicators in its QOF revisions.

Indicators for eGFR in diabetes, thyroid function testing in patients with hypothyroidism and monitoring in patients with lithium therapy were identified as having a ‘higher level of risk' for removal.

The Government and GPC will now negotiate over which indicators to take out, but GP negotiators said they would be pushing for ‘no changes'.

Dr Brian Dunn, lead GPC negotiator on the QOF, said: ‘NICE doesn't fully understand how general practice is funded. If you remove a resource it will have a detrimental effect on that care. That resource is paying for specialist nurses and other staff and if funding is removed practices will have to let them go.'

The BMA's concerns were fuelled as NICE revealed there was some evidence of lower recording of smoking since the indicator's removal, which the institute said highlighted the need to monitor changes carefully.

Dr Colin Hunter, chair of the NICE QOF advisory committee and a GP in Aberdeen, said there was evidence the removal of a smoking indicator last year had resulted in reduced performance, but said it was a ‘no-brainer' to consider removing indicators that led to duplication of payments.

‘An indicator that talks about measurement of blood pressure, and one that talks about getting blood pressure to a certain level - it could be argued there's a bit of double counting.'

Professor Kamlesh Khunti, professor of primary care diabetes and vascular medicine at the University of Leicester and a GP in the city, said the removal of indicators would drive up standards in general practice.

‘We know just measuring does not lead to improved outcomes. If a target leads to improving an outcome you are more likely to measure it,' he said.

But Dr Pam Brown, a GP in Swansea disagreed, saying ‘We are being expected to deliver higher and higher service without being paid. It just doesn't make sense.'

A Department of Health spokesperson said it was keen to identify areas which had become ‘standard practice' and no longer needed to be incentivised.

A spokesperson from NICE said the advisory committee had considered the issues of removing indicators 'in full' and had recommended that when indicators are withdrawn the effect should be monitored.

'There may be a reduction in achievement but it will be difficult to ascertain whether this is reduction in recording or reduction in care,' he admitted.

Forthcoming changes to QOF


• Contraception, conception and pregnancy advice in epilepsy
• BP of 150/90 or in diabetes
• BP of 140/80 or less in diabetes
• TSH testing in adults with Down's Syndrome


• BP, HbA1c, cholesterol records in diabetes
• BP records in patients with TIA or stroke
• BP records in patients with CHD
• eGFR or serum creatinine testing in diabetes
• Creatinine and TSH testing in patients on lithium therapy
• Thyroid function tests in hypothyroidism


• Drug treatment after a myocardial infarction
• Asthma control
• Foot care in diabetes
• Physical checks in schizophrenia and bipolar affective disorder
• Tests in patients with newly diagnosed dementia
• Patient views in palliative care

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