Dr Colin Hunter is the no-nonsense Scotsman who has been at the helm of the clinical domain of the QOF for five years. He has been an astute skipper thus far, but he faces choppy waters ahead.
There is growing resentment among GPs that they have been lashed to a framework that is constantly changing and inflicting greater workload than ever this year. With GPs in England facing upper thresholds rising for 20 indicators, a raft of new indicators introduced and 14 indicators retired from April.
The GPC has called some of the changes ‘dangerous’ for patient care and probably for the first time in the profession, there is a realisation that practices will have to pick and choose the QOF targets they chase this year. The current rate of change is unprecedented, and even the chair of the RCGP has said that the framework is ‘out of control’ and is distorting the care that GPs provide.
Despite this, and an eight-hour journey from Aberdeen, Dr Colin Hunter is surprisingly chipper. Pulse meets Dr Hunter at the NICE headquarters in London – a bland office building with well-worn carpets and magnolia walls – but as a jobbing GP in Aberdeenshire, Dr Hunter is well aware of the pressures that GPs are under.
He agrees that the issue of too many indicators being put into the QOF at a time when funding for resources is dwindling is ‘an issue for patient care’. ‘There’s a burgeoning workload in general practice and therefore the volume of indicators going forward needs to be carefully considered by the DH and the BMA’ he warns.
He says that there are inherent dangers in the Government’s plans to hike up the thresholds of 20 QOF indicators this year in England, and the remainder next year, and urges a review of their impact.
He says: ‘You may actually disincentivise some of the less well achieving practices to do quality care. It’s important this issue should be considered by governments and negotiators.
‘I think when you make changes such as this it’s important to analyse the potential unintended consequences and then observe very carefully what’s happening to ensure those unintended consequences aren’t happening.
‘If they do occur then you need a review of what’s been done further down the track.’
But he dismisses criticism from the GPC that some of the new indicators on hypertension due to be introduced from April could result in patients being put at risk of polypharmacy and ‘dangerous’ hypotension.
He says: ‘All indicators we look at have a strong-evidence base, so I don’t know what the GPC would base that analysis on.
‘We are confident when we look at indicators that come from NICE guidance or from SIGN guidance or from quality standards.’
As chair of the QOF development committee at NICE, Dr Hunter is responsible for scrutinising the evidence that QOF indicators are based on and ensuring any problems have been fully ironed out in pilots before they are recommended to the GPC and NHS Employers for inclusion in the framework.
He explains that the committee follow strict procedures to test whether indicators are, in his own words, ‘QOFable’. These include trialling indicators in real practices and considering the outcome of the evaluation, and opening up the indicators to a public consultation.
He says: ‘We think about feasibility- do they work or not, their ability to give a cost-effective approach, whether we can drop it into the IT or not, what the GPs thought about it, what the patients thought about it. ‘
‘That’s done by a period of public consultation to come to a conclusion about whether the indicator is worthy to put forward the indicator for negotiation.’
The hypertension indicators went though this process, which he considers robust, and so he agrees they should be included in the framework.
‘We believe they are strongly evidence based and that’s why they go forward into the QOF’ he concludes.
Dr Hunter on…
Hiking upper thresholds
‘You may actually disincentivise some of the less well achieving practices to do quality care’
GPC criticism of ‘dangerous’ hypertension indicators
‘All indicators we look at have a strong-evidence base, so I don’t know what the GPC would base that analysis on’
Bundling diabetes indicators
‘The important thing is to trial it, and see if it works before introducing across the QOF’
Obesity in the QOF
‘We have found it extremely difficult in terms of finding good indicators that would work in general practice’
It is this focus on evidence that has earned Dr Hunter the respect of his colleagues, despite being handed what some might regard as a bit of a poisoned chalice at NICE.
He is not afraid to challenge ideas, such as the proposals from the DH to ‘bundle’ the QOF indicators for diabetes to create a mega-indicator worth more than £5,000.
The proposal is meant to encourage practices to ensure all nine checks – such as blood pressure, cholesterol and foot checks – are done in one patient before practices get paid, but he says they need careful testing before they are rolled out.
He says: ‘At the moment we are uncertain as to whether it’s a good thing or not a good thing to bundle indicators.
‘The way to take that forward is to take a small group of indicators and to trial within that to see if bundling improves the health outcomes for patients, or diminishes the outcomes, as both are possible.’
Could other areas of the QOF be bundled? He says that the committee is not currently looking at this: ‘The important thing is to trial it, and see if it works before introducing it as a general sweep across the QOF,’ he says.
Using the QOF to incentivise GPs to urge their patients to modify their lifestyles is another area civil servants – and recently the RCGP – are keen to include in QOF, but Dr Hunter maintains the evidence is mixed.
He says the smoking indicators work well, but admits the committee have found it harder to find an effective intervention for obesity.
He says: ‘The committee over the last few years have looked over various options over obesity and found it extremely difficult in terms of finding good indicators that would work and interventions that would be effective in general practice.
‘Obesity is an important public health issue, especially in the UK and in Scotland, so it’s important we continue to look to ways to do that but it may not ultimately be through the QOF, there may be other public health initiatives.’
It is a characteristically pragmatic response to a complicated problem.
Watch the full video interview here: