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Update: What next for QOF?

As GP practices cope with a step-change in the workload required under this year’s QOF, NICE advisers have already started to plan the next set of changes to the framework.

Meeting inside an anonymous glass tower in central Manchester last month, they defined the indicators they are recommending to the GPC and NHS Employers for inclusion in the 2014/15 QOF (click here for the full table of recommended and future QOF indicators).

After two days of deliberation, NICE came up with a wide-ranging list, including new indicators for hypertension, dementia diagnosis and diabetes and a host of possible future indicators that require piloting before they can be recommended to negotiators.

But the recommendations come at a fragile time, with the GPC warning darkly that GPs are struggling to keep pace with this year’s changes and chair Dr Laurence Buckman branding the QOF a ‘shrunken tick-box exercise’ rather than a supportive mechanism for evidence-based medicine.

Financial outlay

The biggest change next year for most GPs could be the inclusion of points for using ambulatory blood pressure monitoring (ABPM) to confirm every diagnosis of hypertension. This is a change that will require many practices to invest in costly new machinery.

The indicator is in line with NICE guidance from 2011, but has no provision – as yet – for practices to use home blood pressure monitoring if they wish. There are likely to be logistical problems with this if patients are unable to use an ABPM device – long-distance lorry drivers, for example.

Dr Gavin Jamie, a GP in Swindon who runs the QOF Database website, says this indicator will require a significant financial outlay by the practice before it is reimbursed through QOF pay. Click here to read Dr Jamie’s analysis.

Another significant change is the recommendation of a lower blood pressure target of 140/90mmHg for patients aged 79 years and under who have cardiovascular disease (CHD, peripheral arterial disease, stroke or transient ischaemic attack).

This harmonises all the hypertension indicators in the framework, and according to commentators should not be too much additional work – but the experts at the QOF meeting did stress that achievement thresholds would need to be set lower to give GPs room to individualise treatment in patients in whom achieving the lower levels is problematic.

Dr Kathryn Griffith, RCGP clinical champion for chronic kidney disease and GPSI in cardiology, says the indicators are evidence-based: ‘These patients are high risk, we should be treating them to this [level].’

But the GPC, which lobbied hard against the introduction of the 140/90mmHg target for hypertension patients this year, warns of ‘adverse consequences’.

Dr Richard Vautrey, GPC deputy chair and a GP in Leeds, says: ‘Practices are still struggling with the imposed contract and adverse consequences of the tighter hypertension target, and the potential risks of polypharmacy it may bring have yet to be seen.

‘Thresholds actually went up at the same time as the targets went down last year and there’s no suggestion as yet that the Government intends to reverse that.’

Other changes recommended for 2014 include two new indicators for dementia, one requiring GPs to refer all patients with suspected dementia for specialist assessment at a memory clinic and the other rewarding them for keeping contact details for carers of patients diagnosed with dementia.

A seventh proposed new indicator rewards giving tailored preconception advice to women with diabetes.

Second-generation delay

NICE advisors rowed back on a move to include so-called ‘second-generation’ QOF indicators, where GPs have to try a range of measures to hit more challenging outcomes targets before they can claim their QOF points.

In one example of this, indicators for ‘tightly linked’ cholesterol measures in patients with diabetes – which would incentivise practices to initiate or intensify treatment in patients not achieving the lower cholesterol target of 4mmol/l – have been delayed due to technical difficulties with extracting data from GP records. They are being considered for the 2015/16 QOF.

NICE advisors also gave the green light to pilot an indicator for screening and interventions for harmful drinking in patients with hypertension and one for assessing organ damage in patients newly diagnosed with hypertension.

But practices were saved from potential indicators around monitoring of rheumatoid arthritis treatments and headache management. They were rejected outright by the NICE panel, which concluded they were too complex and that standardising care would be better achieved through education and developing enhanced services.