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NICE toughens thresholds and bundles together indicators in blueprint for new QOF

By Lilian Anekwe

GPs will be expected to chase new packages of QOF indicators setting not only a clinical target but also the exact treatments that must be given to meet it, under long-awaited plans from NICE to overhaul the framework.

Advisers from the institute unveiled their blueprint for a new QOF focused on patient outcomes, with packages of indicators a key element alongside significant toughening of indicator thresholds. But NICE experts admitted the moves could have 'unintended consequences', while the GPC criticised attempts to 'micromanage' GPs' clinical work.

Ministers are set to push the new bundles of indicators – of process measures closely tied to outcomes, such as use of at least three antihypertensives – from April 2013 onwards.

The committee decided true outcomes would not be feasible, but close focus on outcomes was needed to encourage GPs to 'do the right thing'.

It agreed to pilot a target for cholesterol of 5mmol/l – but with payment also tied to GPs taking actions within 90 days, intensifying statin dose and hitting a repeat cholesterol target.

And the advisers controversially proposed ratcheting up payment thresholds by as much as 5% for lower thresholds across all QOF indicators, in a move they admitted would have major implications for GP pay.

At last week's meeting in London, the independent QOF indicator advisory committee heard evidence QOF achievement had reached a plateau, as 'arbitrarily set' payment thresholds – between 25% and 40% – 'are no longer serving their purpose'. NICE wants to raise maximum thresholds to the 75th centile, with an upper limit of 95% to avoid overly aggressive treatment, and raise minimum thresholds by a preferred 5%.

But evidence suggests a quarter of practices would then be below the minimum threshold in at least five indicators, and 10% would not meet minimum thresholds for 10 indicators or more.

Professor Helen Lester, professor of primary care at the University of Manchester and a GP in Birmingham, who will lead the pilots, said the new measures 'stress not only the target, but also the process of care'.

The committee proposed drafting tightly linked measures for piloting, and a trial – with thresholds for some indicators raised by 1%, and others by 5% – from April 2013.

Dr Colin Hunter, advisory committee chair and a GP in Aberdeen, said: 'You can't pilot this because you have to do it with real money – even though it may have unintended consequences.'

Dr Brian Dunn, a GP negotiator and chair of GPC Northern Ireland, said: 'Micromanaging indicators we would not be in favour of.' He added: 'I don't think thresholds are an issue for NICE.'

How new indicator package could look

QOF points earned when:

• Cholesterol is 5mmol/l or less
• Appropriate clinical action is taken within 90 days, for example when starting or intensifying statin treatment
• Repeat cholesterol is 5mmol/l or less

Source: NICE independent QOF indicator advisory committee

NICE toughens thresholds and bundles together indicators in blueprint for new QOF