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Public health targets to tie GP pay to patient willpower

GPs are divided over Government plans for smoking, alcohol and obesity to gain QOF outcome targets. By Nigel Praities investigates

By Nigel Praities

GPs are divided over Government plans for smoking, alcohol and obesity to gain QOF outcome targets. By Nigel Praities investigates

Since the advent of the new contract back in 2004, the QOF has become a lightening rod for media criticism that GPs earn too much money for not enough work.

Politicians too have increasingly muttered that the framework lavishes money on GPs for administrative tasks but doesn't judge them on enough hard clinical outcomes with real public health benefit.

That, it appears, is about to change. The Government seems set on revamping the QOF to give it a much stronger focus on public health outcomes - with smoking first on its hit list.

Pulse revealed last week that ministers want tough new targets for rewarding GPs according to how many patients they help to quit, with insiders insisting points for other public health areas such as obesity and alcohol misuse are likely to follow.

In the past week, the Department of Health, in its response to submissions to its QOF consultation, has confirmed it expects to see the framework shift radically in nature.

‘We would expect indicators should focus on delivery of direct health benefit to patients, by measuring interventions with a direct health benefit…or interim outcomes with direct health benefit,' the DH says.

The Government insists NICE is leading the review of the QOF but behind the scenes sources say both the DH and GP negotiators are agreed that GPs will be catapulted into a new era of public health responsibility.

But if GPs wonder just what sort of challenge it will be to drive down smoking rates, they need only look to PCTs, which are struggling badly to reach their quit targets.

Trusts have a target to get four-week quit rates between 35% and 70% for stop-smoking services, but a third say they will fall short or are finding it ‘challenging' this year.

That's despite 34% offering incentives for patients to quit and 76% having some sort of incentive scheme for GPs.

Indeed in many cases, local enhanced services are already paying GPs for smoking outcomes, with carbon monoxide testing to establish whether someone has given up, and an average of £50 paid out for each quitter.

NHS Milton Keynes pays £120 for a four-week co-validated quitter and £40 for when the patient is lost to follow up. NHS Croydon pay £100 for a four-week quit, including £25 at sign up, £25 at three weeks and a further £50 if the person finally quits.

There is evidence such an approach can work. A German study published in the Archives of Internal Medicine last month found paying GPs over £120 for each smoker who remained abstinent for 12 months was cost-effective.

As far back as 2007, NICE recommended a clutch of public health indicators, including one for the percentage of smokers who had quit for four weeks.

That indicator was rejected at because of the expense of measuring cotinine or carbon monoxide levels and a lack of evidence to support the four-week threshold.

Now though, and with the BMA's support, an indicator along those lines is back on the table, even if there is a long way to go to win over some GPs.

Dr David Simpson, a GP in Hamilton, Lanarkshire, says: ‘Is the BMA serious? Does it agree I should be paid less if patients decides they are not going to quit?

‘What is next? If Mrs Extremely Obese does not lose one stone or is seen at McDonald's should I lose pay? If Mr Alcoholic likes his Super Lager too much I should be brought to account?

But other GPs are much more enthusiastic and believe there is evidence QOF outcome targets could work in other areas of public health too.

Dr Chris Ford, a GP in Brent, north-west London and clinical lead for the Substance Misuse Management in General Practice network, says there is strong evidence for a QOF indicator for alcohol focusing on reducing FAST or AUDIT scores below five.

‘People want to do it, they just don't have the skills,' she claims. ‘It's absolutely essential we tackle this through the QOF. Just because it is difficult to do, doesn't mean we shouldn't do it.'.

Pulse understands the Department of Health is currently conducting behind-the-scenes research into the feasibility of greatly expanding the number of points for reducing alcohol misuse in the QOF.

Obesity too may eventually be awarded outcome-related QOF points, although only if NICE is convinced that there is good evidence for the benefit of GP interventions.

The pioneering Counterweight Programme – an intensive anti-obesity scheme led mainly by practice nurses and supported by dieticians and weight management advisers – is attempting to plug that evidence gap.

Counterweight has been running for nine years and is currently being rolled out in Scotland. It has achieved weight loss of at least 5% in nearly a third of patients, with an average loss of 2.3kg.

But the researchers found a major barrier to GP participation in the programme was lack of resources and welcome moves to add new obesity points to the QOF.

Dr David Haslam, clinical director of the National Obesity Forum and a GP in Watton-at-Stone, Hertfordshire, says it is important to move the QOF away from process indicators, but warns it is too early to have full outcomes targets based on percentage weight loss.

‘The obesity register is a complete waste of time. All you are doing is registering people and assessing them in a year's time to see if they should still be on it,' he says.

‘But equally, I don't think we should incentivise for pounds lost, because I don't think that is fair as there is not a level playing field across the country, with schemes and programmes that patients can use.'

Dr Paul Aveyard, a GP in Solihull and a member of the smoking cessation guideline development group at NICE, believes the same lack of a level playing field exists for smoking services too.

‘Successful cessation is like diabetic retinopathy. To some extent occurrence of retinopathy depends upon the doctor's efforts, but to a fair extent it does not.

‘I would support changing the QOF to ensure patients are offered evidence-based treatment for tobacco dependence, not simply told to quit,' he says.

The GPC is acutely aware of such difficulties in access to services, and seems to have been put in an embarrassing spot by the wider BMA's enthusiastic endorsement of smoking-cessation outcome targets.

GPC negotiator Dr Chaand Nagpaul warns: ‘It's unfortunate the Government is pursuing this mantra of outcomes without understanding that process is inextricably linked to outcomes. I think the right approach is what we have currently to support GPs to record smoking status and give smoking cessation advice.'

But there is no denying the political momentum behind the move for new public health targets. MPs on the health committee warned earlier this month that the target of reducing health inequalities by 10% before 2010 was in danger of being missed without radical action.

‘Tackling health inequalities should be an explicit objective during annual QOF negotiations and should have measurable characteristics,' it said

‘The QOF should be adjusted so that less weight is placed on identifying smokers and more weight placed on incentives to stop smoking.'

But are outcome targets really the best way of narrowing health inequalities? Not everyone thinks so. Professor Helen Lester, professor of primary care at the National Primary Care Research and Development Centre Lester, is among a number of academics who think they could even have the opposite effect.

She says: ‘Outcome indicators clearly represent the ultimate goals of care and are more immediately meaningful to policy makers and patients. However, the key problem here is one of attribution – outcomes can be influenced by issues outside the control of primary care such as patient-related factors.'

The QOF may be heading for radical change, but some fierce battles remain to be fought over its future.

How obesity targets could work

QOF points for obesity are controversial because of a lack of evidence interventions can work – but GP Dr Matthew Capehorn believes his own experience can point the way forward.

Dr Capehorn has gone from having a lunchtime obesity clinic at his practice to setting up his own institute in just nine years.

The Rotherham Obesity Institute will open next month and be the first in the UK to provide a comprehensive obesity management pathway for adults and children.

GPs, specialists and patients themselves will be able to refer themselves to his clinic, if an initial 12-week obesity management programme does not produce results.

Dr Capehorn supports moves for more obesity points. ‘All we have to do is get a fat person on the scales, say "Thank you very much, we have our QOF points and you can go." And do nothing about it.'


What does the Government want to do with the QOF?

The Department of Health says it wants to ensure the QOF is focussing on the delivery of ‘direct health benefit' to patients. NICE, which will develop future indicators, will place a heavy emphasis on hard clinical outcomes.

In which areas are outcomes targets going to be set?

Government insiders say negotiations are taking place between the Department of Health and the BMA for new outcomes indicators, starting with points for smoking quit rates and likely to be followed by ones for weight-loss and reducing alcohol intake.

When might this happen?

Possibly as early as 2010/11. By this time NICE will be some way through its cost-effectiveness review of current indicators and it will have a rationale to remove some indicators and replace them with outcomes-based measures.

Why can't local enhanced services be used?

The GPC argues they should, but others say this local approach will lead to an increase in health inequalities. The DH is considering issuing a menu of NICE-approved indicators that PCTs can pick and choose from, although this has also proved controversial among GP leaders.

Dr Peter Joliffe Dr Peter Joliffe

It is unreasonable to make GPs responsible for all social problems.

Ministers want smoking cessation points based on results

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