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NICE gives green light to divisive 'bundled' diabetes QOF indicator

NICE advisors have approved a controversial ‘all or nothing’ QOF indicator that could see practices only being paid if they carry out eight separate checks in each diabetes patient, despite warnings from pilots that GPs found it demotivating.

The decision means the ‘bundled’ diabetes indicator - incorporating up to eight clinical processes, such as cholesterol, blood pressure and foot checks - will be included in negotiations over the 2015/16 GP contract.

This was despite results from the pilots, unveiled at the NICE QOF advisory meeting taking place in Manchester today, showing that practices testing the new composite indicator believed it was ‘unacceptable’, with less than half (45%) supporting its introduction into the QOF, while 40% were not supportive.

Practices with reservations cited practical issues around the delivery of care at different times in different places, potential unfair impact on practice achievement and risks of demotivating general practice.

The NICE committee acknowledged the ‘all or nothing’ nature of the indicator ‘might have a demotivating effect on practices and may raise exception reporting rates, but agreed they would put forward the bundled indicator for inclusion on the NICE menu for 2015/16.

The indicator will now be put forward for negotiations between the GPC and NHS England for next year’s GP contract.

The bundled ‘all or nothing’ diabetes indicator - in which practices are rewarded only if they achieve all of a series of process indicators - was put into development at the behest of the Department of Health after National Diabetes Audit results found many patients were not undergoing all of their recommended check-ups on annual basis, even though practices were achieving high scores on individual diabetes QOF indicators.

Despite objections raised by the GPC and an independent review concluding differences in coding contributed to disparities between the audit and QOF results, NICE went ahead with piloting an indicator made up of eight of eight clinical process measures - see below - this year.

During pilots of the bundled indicator, achievement of all eight processes improved from 46% in 2012/13 to 27% during the six-month pilot, which the QOF researchers said would translate to a slight increase to 53% if the results were extrapolated over a full year.

However, there was an increase in exception reporting, which rose from 7% at baseline to an estimated 11%.

Summing up, committee chair Dr Colin Hunter noted that despite some process indicators being removed, the bundling of indicators was ‘feasible’.

Dr Hunter said: ‘What we might be able to say is bundling of a number could be considered, but that the individual nations would need to continue to monitor the impact, that there may be unintended consequences in terms of increased exception reporting and so could diminish the care of some patients, although it will enhance the care of others.’

Speaking to Pulse after the meeting, Dr Hunter explained he did not personally support the idea of bundling indicators, but the consensus view of the committee was to recommend the composite indicator.

Dr Hunter said: ‘What we’re saying is this composite indicator in diabetes would work and deliver. There is a view it might improve quality of care because you might get more patients who get all the facets done. But there is already some evidence that exception reporting might increase, which might actually mean across the piece there is a downside.

‘We will put a caveat in about the potential downsides.’

He added: ‘I’m an “unbundler” myself - I think it’s much clearer to have the individual processes, it means people go through it in a more logical way. But this is NICE’s view.’

QOF expert Dr Gavin Jamie, a GP in Swindon, said the complexity of the indicator could put off GPs.

Dr Jamie said: ‘It will inevitably push up exception reporting because it If there’s any one of eight things is not feasible you’ll have to exception report them for them all.’

Readers' comments (18)

  • Idiots.
    Unbundling is far more effective when looking at behavioural economics and efficiencies.

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  • Now means we are reliant on an ineffective podiatry service that has no interest in practice income

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  • Vinci Ho

    Nobody is surprised that is coming
    The rise in exception reporting will trigger what?
    Knock , knock
    Who's there?

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  • More appointments lost for administrative reasons. My advice would be for practices to make administrative time obvious to patients/ public/ press.

    Like a QOF day/ afternoon once a fortnight where there are no routine appointments available and anything apart from palliative care emergencies being delayed/ diverted to A+E.

    Give them a letter saying this is because QOF work has increased and when they keep giving it to A+E it will eventually get back to those in charge that piling work onto GPs costs more money than it saves.

    Do not work yourselves into a grave doing this work in your own time, it will just encourage them to pile on more and more.

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  • This is probably harmful.

    Exception reporting will shoot up and those exempted patients will just get ignored leaving their care to stagnate over the years.

    Once exempted the chance of subsequent exemptions is threefold.

    Not good NICE.

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  • I think I see the merger of a few stories here. considering some practices have started de listing patients and the possibility of making QOF increasingly difficult this would be an obvious route to select patients to de-list.
    In terms of public health it would be counterproductive but practices need to start doing this - as this is the only way NHS England will start to take notice.

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  • Practices will need to consider whether it is economic to continue providing diabetic checkups, or to withdraw the service completely (and presumably refer all to the hospital diabetic clinic, just like the good old days!)

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  • Easy - as suggested above - refer all to hospital clinics.
    code results from letters.

    If all checks not all done or included in letters complain to hospital and get them to do send results for all the checks required.

    Provide a high quality service for the patients while not disadvantaging your other patients with wasted time.

    Stick to core work and send unfunded or unreasonable work back to secondary care. Learn to say NO.

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  • Bundled indicators is designed to reduce pay. Same as bundling football matches to increase ticket sales . It's an economic strategy rather than a clinical one . the response is clear - send everyone to hospital clinics and concentrate on other areas .

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  • NICE says its risks demotivating GP's. Given its already low the bonus is its unlikely to go much lower!

    There is a theme over the years though. Belgrano was steaming away from Falklands so we'll sink it anyway. Poll tax is daft, the trial in Scotland said so so we'll do it anyway. Contracts are either imposed (showing my age Mr Clarke) or in the inaccurately costed one risk NHS meltdown if you dont accept. Also lets go to war because of risks over WMD but its a bit inconvient when can't actually find them. Basically if we think its a good idea we'll do it despite any number of sensible, rational, competent, logical, appropriate reasons not to and when it doesnt work it cant be our fault!

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  • i think this is the right move--QOF being voluntary many practices are not fulfilling the care obligations and this is costing the NHS millions in unplanned admissions and poor outcomes for the patients-as a GPwSI i fully support this move--my colleagues have to get on with the full care protocols

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  • I cannot get the wee out of them for their urine test nor force them to have an eye screen - others ok

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  • Check ups are one item,choice therapy in diabetes 2nd line treatment according to Prof. Anthony Barnet NICE Guidelines adviser and prof of Endocrinology is a much more important one.Hypoglycaemias can kill,cause RTAs,Metabolic consequencies of PCT recommended Sulphonyureas is a factor worthy of much more consideration and condemnation.Further side effects and closer follower ups may be reduced with less pressure to GPs

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  • GPs are demoralised by PCTs insisting on hypoglyceamia inducing suplonyureas as second line tratment in D.M. ,contrary to EBM Prof Anthony barnet's comments on dangers of Suphonuureas as 2nd line treatment in DM.More follow ups are required with little health gain by the patients .
    Burnt out has become the fate of most conscientious GPs

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  • All of these top down directives have short term drivers and are largely led by short term funding objectives.NICE has a track record for looking at the evidence(recognising bundling will disincetivise) then making a short term cost driven ruling in line with central diktat(who fund them)
    Generally where GPs recognise this , gaming strategies de listing, temporary residenting and O/P referral .Vaccine and Cx smear targets in the past. The patients are individual not a bundle of boxes to be ticked. Diabetic care will worsen and cost will not be reduced.

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  • One more nail to add to the coffin of good general practice. Consider the patient, develop a "written" personalised shared care programme, but everything on NICE's list has to be done anyway, even if the patient does not need it or would not benefit! I don't think we'll do it in our practice but I applaud those who will refer to the diabetic clinic at the hospital (if there is one). NICE do assume that any QOF item is pump priming, and can be withdrawn at no cost to the patient and "spent" elsewhere. They have to be made to realise that reducing the funding for services means an inferior service, and that means more of us need to stick our neck out and say "no". It will be sad to lose an aspect of the health service which has been an envy of the world, but the one sided ability of the NHS to change any aspect of our contract at the drop of a hat makes partnership much more risky and less attractive. Time was , I might have stood up for the decisions of NICE , but now I think they are far too politically involved so I will tell patients they "call themselves" the NI for care excellence, rather than agreeing that that is their purpose.

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  • Okay so this about patient compliance rather than patient consent. Somerset are allowing GP's to opt out of QOF so why allow patients themselves to opt out of being treated under QOF. QOF is very paternalistic and will one day give me hypertension just from thinking about it!

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  • I have always told my patients that some idiotic rulings are not mine and some very highly educated political yes men. I have to do it and I will has been told but it makes no medical sense to me.I leave it to the patient to say yes or no. If he says no I freely exception report these at patients request. I am sure with this new idiocy Ill have to be exception report more-to the detriment of patients care? or who is bothered with the patient as far as all boxes are ticked. NHS has become more concerned with the process rather than the patient. As far as all boxes are ticked and patient dies due to complications NHS as offered excellent care!!!!

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