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Independents' Day

MPs back plan to bundle diabetes QOF indicators

MPs have backed Department of Health proposals to bundle most of the diabetes points in QOF to create a single indicator worth over £5,000.

The Public Accounts Committee - a cross-party committee of MPs - said the National Diabetes Audit had shown the current QOF system was not driving better outcomes and GPs needed tougher targets.

The calls come as Pulse obtained a copy of an investigation by the DH into discrepancies between the results of the National Diabetes Audit and QOF.

The investigation shows that performance under QOF may be even lower than previously thought, with only 40% of patients with diabetes receiving all nine checks.

The authors of the report admit it was ‘very unlikely’ GP performance was this low in reality – particularly as performance for the individual indicators was over 90% - but it gives ministers more ammunition to push through changes to the diabetes points in QOF.

Pulse revealed in July that ministers had written to NICE to ask it to explore the practicality of raising QOF thresholds and creating a ‘composite’ indicator in QOF for diabetes.

The composite indicator would include current indicators for measurement of HbA1c, cholesterol, blood pressure and foot checks, in an attempt to boost achievement in the routine assessment of patients with diabetes.

This proposal has been condemned by the GPC as ‘demotivating’ for GPs, but the proposal looks almost certain to go ahead after it was backed by an influential group of MPs.

In their report, the PAC said the DH was not ‘effectively incentivising delivery of all aspects of its recommended standards of care through the payments systems’.

They added: ‘GPs are paid for each individual test they carry out rather than being rewarded for ensuring all nine tests are delivered.’

The committee cited evidence from the NDA that only half of patients with diabetes were receiving all nine checks from GPs.

The DH investigation into the differences between QOF and the NDA was carried out by RCGP revalidation lead Professor Nigel Sparrow who heads up the Composite Markers Diabetes Sub Group.

It found differences in the read codes used to record the care processes for urine microalbumin, smoking and eye checks were found to largely account for the differences in results.

Professor Sparrow said the investigation showed that there had been improvements in the treatment of patients with diabetes, but that not all activity was recorded by practices.

Professor Sparrow said: ‘The report is very positive in that we can demonstrate really significant improvement in the care of patients with diabetes and the apparent differences between the NDA and QOF are due to the codes used.’

‘The 40% figure is a based on a mathematical calculation showing what is possible although very unlikely in reality.’

But Dr Bill Beeby, chair of the GPC clinical and prescribing committee, said the  40%, figure was not reliable.

He said: ‘Mathematical calculations are not reality. To base decisions on mathematical calculations that are not reality wouldn’t be very sensible.’

He added that a composite indicator would give practices a ‘perverse incentive’

He said: ‘It is not as simple as doctors telling patients what to do, people have to want to achieve it and have to be able to achieve it.

‘What you’re saying is that a practice who have done eight tests but not the ninth is retinal screening which is out of their control would not receive any reward.

Read the full report here.

Readers' comments (10)

  • Last year our local podietry had difficulty doing the required checks, despite our repeated pleas to do them - they had staffing problems apparently.

    So we would have lost all the QoF money had this been in the place. In which case I would have probably had to reduce my nurses hours and admin staff who normally deals with DM and not bother with DM indicators at all this year. Yes its not a good clinical practice and I'll still continue to do them where possible but if the government is so insistent on driving our good clinical practice into the ground, what other choice a common GP has?

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  • Perhaps they want Virgin to set up a one stop shop for diabetes. They will probably pay them an item of service for each patient who turns up. The HCAs who see the patient will then send 'helpful' letters to the GP for us to still do the hard work.

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  • Sounds like another ploy by politicians to steal more money from General Practice incomes. When QOF was first invented, politicians never expected Primary Care to achieve nearly full points. The scheme actually backfired into their faces. However, the future now looks bleak for QOF incomes.

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  • QOF areas will be put up for tender to the cheapest offers and MP's will say

    ' there you are Doctor, we have freed you of this burden to allow you more time to do everything else' Whilst of course taking the money with them.

    In the words of Dads Army ' we're all doomed!'

    Retire asap or go private although that of course will require far fewer doctors if you want to maintain your income!

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  • I will be interested to see the results of the investigation into differences between QOF and the NDA. Although the NDA extracts data on the results of a test for microalbuminuria they do not use them to determine whether or not a test has been performed. So, if a GP only enters the read code for the result of the test but does not also enter the read code to say that the test has been performed, the NDA assumes that the test has not been performed. The NDA does, however, use the result of the test in other parts of the report, so clearly they think the results data are valid. This seems to me to be an error in the NDA analysis. Quite how they expect us to get a result without having performed the test is beyond me.

    Recording only the result and not the fact that the test has been performed is in accordance with the principles in section 1 of the "Quality and Outcomes Framework guidance for GMS contract 2011/12" http://www.nhsemployers.org/SiteCollectionDocuments/QOFguidanceGMScontract_2011_12_FL%2013042011.pdf

    where principles 2, 3 and 4 are:

    #2 The number of indicators in each clinical condition should be kept to the minimum number compatible with an accurate assessment of patient care.

    #3. Data should never be collected purely for audit purposes.

    #4 Only data which are useful in patient care should be collected. The basis of the consultation should not be distorted by an over emphasis on data collection. An appropriate balance has to be struck between excess data collection and inadequate sampling.

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  • Let common sense prevail

    The day when MP's advise me how to manage my chronic disease patients has to be the day when I seriously consider early requirement.

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  • Don't like to be picky, but Anonymous | 09 November 2012 5:15pm, the QOF payment is essentially your surgery doing the foot checks, independently of Podiatry. It is nice if they report back on patients in their care, but if Podiatry weren't able to complete, you should have stepped into the breach.

    Anonymous | 11 November 2012 6:49pm, totally agree with you regarding #2,#3 & #4. NDA made a horlicks of their analysis and patients wishes regarding tests and their own compliance should not be countermanded for the sake data collection.

    As a non-compliant Retinopathy patient myself, I don't want to make my surgery lose money or sour my relationship with my doctors, because I don't comply.

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  • I've read the report on reasons for the discrepancies.
    Have the MPs?

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  • Just a thought: do the MPs realise that what they are calling for is a change in QOF from aggregated data to fully identifiable data?
    Just think of the implications for confidentiality - and the technical aspects of data extraction (and storage).

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  • I see that Pulse Today has made a scanned copy of the report available, but the NDA have not published it. Because the NDA have under-estimated the number of patients that have had at least one of the nine processes of care, as far as I can see the report effectively says that the previous NDA findings on achievement of the nine processes of care were wrong, probably very, very wrong. I know of at least two PCTs that achieved high scores on one of the processes according to QOF (over 85%) and very low according to the NDA (around 30%) on one of the indicators. These PCTs could not possibly score more than 30% on the nine processes of care because of this one indicator. This report now shows that it was a problem with the NDA analysis.

    They were quite active in naming and shaming PCTs previously but they have not published the report (dated 31 August 2012). Thank you Pulse Today for making this available.

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