NICE is currently consulting on and piloting the indicators it is considering putting forward for the 2015/16 QOF. If the proposals are approved they will in the summer be presented to NHS England and the GPC negotiators for possible inclusion in the contract. But whether NICE’s proposals become reality changes from year to year – none of NICE’s proposed indicators made it into the final 2014/15 QOF while almost the entire list went in 2013/14.
Overall NICE’s package of proposed changes feels like a step backwards for QOF, although it is likely that the NICE committee has rather been overtaken by recent events. The indicators take time to develop and the medico-political landscape has changed dramatically since they were first suggested.
All of the proposed indicators are about processes, whereas the direction of travel for the QOF now is moving to outcomes. There is a broad spread of small indicators at a time that QOF is looking to focus on a reduced number of targets. There will be some tricky coding, at a time that when ministers are looking to reduce bureaucracy. I wonder how many of these proposed indicators will end up making it past the negotiators.
The most ambitious of the potential new indicators suggested for 2015/6 would reward practices for performing eight annual checks in each patient with diabetes. These are based on the nine care processes measured in the National Diabetes Audit – the exception is retinal screening, which normally takes place outside the practice.
The requirements of this potential ‘bundled’ indicator are similar to QOF indicators of old – based entirely on processes rather than outcomes. It is the taking of the blood tests and the measurement of blood pressure that would be rewarded, rather than achieving specific blood pressure levels or serum cholesterol.
The clinical requirements are relatively simple and could be tackled in twenty or thirty minutes by a nurse-led clinic. Three checks will be covered by a single blood test and a fourth, the albumin:creatinine ratio, would require the patient to bring in a urine sample. Measurement of BMI and blood pressure are also pretty straightforward, as is recording the patient’s smoking status. A diabetic foot check takes a little longer, but previous QOF results show that practices performed this check in over 90% of patients in 2012-13.
The National Diabetes Audit has tended to show historically that few practices have undertaken all eight processes in every patient, although the NDA has different codes to the QOF. Results for the same work have always tended to be worse in the NDA than the QOF, most likely because GPs are working towards the QOF codes and not the NDA ones. One example of this locally was where practices were using dipstick testing for microalbuminuria. The NDA did not recognise the way this work was coded and so our area appeared quite low in its rankings.
Ensuring that all eight separate processes are coded correctly will be complicated. Current compound indicators (such as prescribing in coronary heart disease or blood tests at the time of dementia diagnosis) can be difficult to manage, as it can be difficult for practice computer systems to identify which interventions are still required if you begin the work. Where eight separate codes are required, the burden from this indicator is more likely to be administrative than clinical.
As well as the bundled diabetes indicator, there are clutches of simple indicators for patients newly diagnosed with hypertension. Five separate indicators would require all patients to have an ECG, urinary albumin:creatinine ratio, haematuria testing, alcohol screening and advice to reduce alcohol if they are drinking too much.
This is probably more work per patient than the diabetes indicators and could potentially represent a disincentive to diagnose hypertension. There will be fewer patients involved in the new diagnosis of hypertension than in all patients with diabetes. If this proposal goes ahead, practices may want to delay making the diagnosis until the patient attends a formal assessment clinic.
The two proposed indicators for giving advice to women who are on the mental health register and receiving drug treatment, and who are pregnant or trying to conceive, are similar to those currently in the epilepsy area of the QOF, and would only apply to quite a small number of patients. These would become another couple of boxes to tick at annual review, at a time when most of the physical health indicators are about to be removed from the mental health area.
Medication reviews disappeared from the QOF in April 2013, along with the rest of the organisational domain, but they could return for patients on ten or more medications.
Finally, the proposed requirement for patients with COPD who have recently needed oral steroids to have a supply of antibiotics and steroids at home may well be something that practices already do.
The consultation runs until 3 February and I would encourage practices to respond. The more responses from GPs, the better this process will be.
Details of how to respond can be found here
Dr Gavin Jamie is a GP in Swindon and runs the QOF Database website.