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Independents' Day

NICE advisors refuse to back ‘next generation’ of QOF indicators

NICE advisors have rowed back from recommending ‘next generation’ QOF indicators that incentivise practices to achieve clinical outcomes in fixed groups of patients, arguing that they were ‘ferociously complicated’ and would be difficult to implement in practice.

The Primary Care QOF Indicator Advisory Committee heard the new type of clinical QOF indicator - seeking to reward changes in GP behaviour – currently being piloted by NICE - have proved complex and contradictory.

The so-called ‘tightly linked markers’ are aimed at encouraging GPs to improve the outcomes of patients, such as reviewing cholesterol levels in diabetic patients and initiating or intensifying statin therapy.

In a scheme piloted in 66 practices, GPs were expected to identify patients with type 2 diabetes who had a cholesterol over 4 mmol/L, and to start them on a statin if they weren’t already on one. For patients already taking a statin but had a cholesterol over 4 mmol/L, GPs were expected to increase the dose or change to a different drug.

However, results from the pilot found the indicator resulted in only minimal changes in outcomes and was too complex and difficult to implement for GPs.

The pilot showed only a very small increase in the proportion of patients with poorly controlled cholesterol with statin therapy initiated or modified during the 12-month pilot had a very small increase - from 3.1% to 3.9%.

Reviewing the findings yesterday, GP members of NICE Primary Care QOF Indicator Advisory Committee said the new proposed new indicators were ‘ferociously complicated’ and would be difficult to implement in practice.

They questioned the rationale for introducing an incentive for intensifying statin therapy in patients with diabetes, when evidence suggested that all patients would benefit from statins regardless of
lipid levels.

They also suggested that the indicators would promote ‘statin churn’ and that they would penalise GPs who measured cholesterol more frequently if these showed patients weren’t in the target range.

A NICE adviser said the new indicators had been received positively by most of the pilot practices , and they only required 10 minutes of explanation.  They were keen to see the first TLM introduced as a ‘template’ for more indicators that linked clinical processes with outcomes.

However, the committee concluded that there were serious issues with TLMs that needed to be addressed before they could be considered for introduction.

Readers' comments (5)

  • Hmmm? What's happened to the informed discussion we as GPs were encouraged to have?

    It's gonna be "you'll take this pill wether you like it or not, otherwise I wont make the money" now is it? I assume the Good doctor guidance from GMC and the RCGP's CSA will change to reflect the new approach encouraged by the government

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  • Vinci Ho

    The last thing you want is turning into a right wing medicine preacher enforcing medications without caring about patients' feelings........

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  • Mark Struthers

    There really is nothing more meaningless than a cholesterol level ... and something 'ferociously simple' about the 'Primary Care QOF Indicator Advisory Committee' apparatchik.

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  • Mark Struthers

    I read an article like this and all I can think of is donkeys, carrots and idiots with sticks. The cholesterol level is meaningless and measuring it should be stopped ... for ever!

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  • QOF is about as tightly wedded to the biomedical paradigm as it is possible to be. Associating QOF with payments almost completely excluded the patient as person from care. Many of our current biomedical indicators are subject to intense debate and yet these are the things that are being used to determine "care". Despite this it has been repeatedly shown that patient-centred care (biopsychosocial model) achieves better outcomes despite a less regid adherence to the biomedical paradigm and rigid clinical targets. QOF was an attempt to control what we do without any real understanding of what it is that we do in General Practice. Clinical guidelines etc are just that: guidelines. They are an invaluable tool for assisting the provider and the patient to achieve the best outcome for the patient. QOF has failed to deliver really meaningful benefits for patients because it functions in the wrong paradigm and has diverted the real attention from the patient (as a person) to a target (which may be meaningless). I am with Mark Struthers on this: donkeys, carrots, idiots with sticks.

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