The combined diabetes indicator would create a cliff edge in payments and could put practices off doing any of the elements because of worries that a patient may not engage enough to complete the package. This is particularly true for opportunistic care which is often the only way hard-to-reach patients can be engaged.
It would be very unfair to practices that do a lot of work achieving all but one element of a diabetic programme only to lose all the funding because the patient did not attend for a cholesterol check or return a urine sample.
It also ignores that fact that many patients with diabetes have other long term conditions. Practices see many patients opportunistically and it is surely better to do some of the elements required by QOF during each consultation – every contact counts – which does risk the patient not returning for completion of the other elements.
Patients are human and do not all fit in to rigid guidelines and as adults can choose not to engage in treatment offered. It is also important not to overwhelm patients, and good medicine often involves discussion with the patient about what they feel is important and achievable, and concentrating on one thing at a time. The proposed approach might well cause overall care to be worse as patients give up and disengage.
There is also little value in measuring some of these indicators on an annual basis. In particular we believe the annual measurement of the following are unlikely to change management: ACR in patients known to have microalbumiuria or already on an ACE1 inhibitor; lipid measurement for patients already on treatment or who have declined or are unsuitable for drug treatment.
The overall effect of these changes will be to reduce the resource available for practices to deliver care to patients with diabetes, and the practices with the hardest-to-reach patients will be most affected.
Source: GPC’s response to NICE’s recommendations for QOF