Tougher diabetes targets will 'neglect highest risk patients'
By Lilian Anekwe
The decision to toughen up the QOF diabetes targets has sparked a row between experts amid claims that GPs will be forced to ‘concentrate their efforts in the wrong place'.
One GP advisor to NICE has claimed that the more stringent new HbA1c indicators could cause GPs to neglect the patients at highest risk.
Current indicators, which reward GPs for hitting HbA1c levels of 7.5% and 10% or less, will be – will be replaced with three new indicators for HbA1c levels of below 7, 8 and 9%. This means GPs will no longer get QOF points for any patient whose HbA1c is between 9 and 10%.
The new targets are intended to bring the QOF more into line with guidance on type 2 diabetes issued by NICE in May, which recommends GPs target an HbA1c of 6.5%.
But Dr Martin Hadley-Brown, a GP in Thetford, Norfolk, and a member of the NICE guideline development group, said he was ‘very disappointed' with the decision not to incentivise GPs for lowering higher ranges of HbA1c.
‘The incremental benefits from lowering HbA1c from 7.5% to 7% are nothing compared with from 11% to 10%, or 10% to 9%. We're concentrating our efforts in the wrong place.
‘There's a missed opportunity in prioritising and drawing attention to people with very high HbA1c and lowering it. This removes the incentive for practices to do that.'
Dr Hadley-Brown also questioned whether chasing very low HbA1c levels in all diabetes patients was either achievable or safe.
‘There's already an argument about driving down people with fairly low HbA1c to an even lower level,' he said. ‘We will also have to drive elderly people lower - that could potentially not provide benefit and maybe a risk.
‘I understood things in the QOF are meant to be achievable by the majority of practices. I don't think this is.'
Dr Jonathan Graffy, the GP co-author of the evidence report for the diabetes QOF indicators, defended the new targets.
‘There's no pressure on GPs to treat patients inappropriately. The QOF does not require everybody to get to those levels – the indicator for the 7% target is set at 40-50%. Is that achievable? Yes, definitely.'
Dr Graffy, who practises in Waterbeach, Cambridgeshire, insisted patients with HbA1c levels above 10% would not be neglected.
He said QMAS data and the national diabetes audit showed that about 8% of people had an HbA1c above 10%. ‘At the moment GPs are not stretched and don't have to do anything more in that group. By lowering the target we are bringing more people into the incentivised group, so more should benefit.'New diabetes indicators
DM 23: % of patients with diabetes in whom the last HbA1c is 7 or less in the previous 15 months. 17 points; thresholds 40 – 50%
(Replaces the target of HbA1c of 7.5 or less)
DM 24: % of patients with diabetes in whom the last HbA1c is 8 or less in the previous 15 months. 8 points; thresholds 40 – 70%
DM 25: % of patients with diabetes in whom the last HbA1c is 9 or less in the previous 15 months. 10 points: thresholds 40 – 90%
(Replaces the target of HbA1c of 10 or less)