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NICE points way to leaner QOF

A report from NICE’s advisory committee has offered GPs the first indication of how a pared-down QOF may look

The abolition of controversial QOF indicators for biopsychosocial assessment in depression and physical activity checks in hypertensive patients is on the agenda, as part of NICE’s proposals to scale back the QOF from next April.

NICE has also given the go-ahead to restore a 15-month timeframe for annual QOF indicators, deciding the 12-month cycle introduced this year has increased workload without improving patient care.

With wide-ranging changes to the GP contract expected to be set out by the GPC and NHS England ‘within weeks’ and health secretary Jeremy Hunt clear he wants a reduction in ‘box-ticking’ targets, GPs have been given the first indications of how the QOF might be reshaped to free up their time for other activities.

In a review commissioned by NHS England, NICE recommended scrapping some indicators that have ‘little impact’ and proposed a rethink of the requirement for practices to issue three invitations to QOF review appointments, pointing out that most patients who attend do so after a single invitation. 

A special meeting of the NICE QOF advisory committee concluded there was ‘much to be gained and little to be lost’ by reverting to the 15-month timeframe, stressing that the 12-month span puts GPs under even greater pressure during the peak winter workload period.

NICE agreed the DEP001 depression indicator, which requires a biopsychosocial assessment at diagnosis, ‘adds to workload as it interferes in the natural process of these often long and complex consultations’ and it ‘could be removed with little impact on quality of care’.

The committee also conceded there would be ‘minimal impact on patients’ health’ from dropping the unpopular HYP004 and HYP005 hypertension indicators, which require GPs to screen patients’ physical activity using the GPPAQ questionnaire and advise those with low scores on exercise.

Other suggestions from the NICE advisers included ‘recycling’ clinical domains, with areas removed and reintroduced periodically.

Dr Mike Bewick, deputy medical director at NHS England, told Pulse the aim of the QOF overhaul was to ‘minimise the areas where it’s purely tick-box and adds no value’.

He added: ‘You don’t want to throw the baby out with the bathwater. We want to ensure we keep the best of QOF but equally, having been a GP myself, I can remember the frustration of having to tick boxes which were inappropriate.’

How might the QOF change from April?

NICE advisers recommended the retention of all indicators on AF, CHD, PAD, hypothyroidism, asthma, COPD, dementia, mental health, cancer, palliative care, epilepsy, osteoporosis and rheumatoid arthritis.

They concluded the following could be removed from the QOF:

• 12-monthly annual reviews (revert to 15-monthly)

HYP004 and HYP005 – physical activity in hypertensive patients (worth 11 points in total)

DEP001 – biopsychosocial assessment in depression (21 points)

OB001 – obesity register (8 points)

• Learning disability indicators LD001 and LD002 (7 points in total)

• Maternity (MAT001) and child health surveillance (CHS001) (12 points in total) – more appropriately delivered through CCG outcomes indicator set

DM0015 and DM0016 – could be temporarily removed or rolled into DM0014

• ‘Some’ CVD prevention and smoking indicators

NICE also recommended review of:

• Requirement for three invitations to review appointments

• CKD indicators – to be reviewed after NICE guidance update

• Contraception and cervical screening indicators – to be reviewed with Public Health England input

Source: NICE QOF committee – meeting minutes

Analysis

Fifteen-month reviews always made sense. If the target is 12 months, too many people end up having to be reviewed in 10 months. There was never a good reason for changing this.

It makes sense to drop DEP001. While the concept of biopsychosocial assessment is a sound one, it’s simply not amenable to putting into a box to tick. This is a good example of a very important aspect of care that simply isn’t amenable to QOF-type indicators.

QOF is never going to cover some major and important aspects of care, because they can’t readily be measured. This is one of the reasons why I think QOF should make up a smaller percentage of GPs’ income – around 10% would be better.

Professor Martin Roland is professor of health sciences research at the University of Cambridge and a GP in Cambridge. He had a major role in developing the original QOF

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