Last summer, the NICE QOF Advisory Committee asked NICE to develop new indicators for the depression domain, and my Birmingham University-based team were tasked with creating new indicators. The committee asked that they would be evidence-based, would make sense to practices and above all would improve the experience of primary care for people with depression.
Two indicators were piloted in 30 representative practices across the United Kingdom from October 2011 to March 2012:
1. The percentage of patients with depression who have had a bio-psychosocial assessment by the point of diagnosis.
2. The percentage of patients with a new diagnosis of depression (in the preceding 1 April to 31 March) who have been reviewed within 10-35 days of the date of diagnosis
Overall, the59 primary care staff surveyed said the indicators were an improvement on the existing depression indicators, and were more reflective of good clinical practice and NICE guidance.
The focus on a qualitative and more holistic approach to patient assessment in indicator 1 was viewed positively – and indeed, it was reported to reflect usual clinical practice and was seen as more patient-centred than using structured questionnaires such as PHQ9: ‘You can incorporate [the bio-psychosocial assessment] into your consultation, it’s a lot less intrusive, and it’s something which you would naturally do anyway, it’s not much of a deviation from what feels the best for your patient’ (GP, Practice ID: 2).
However, approximately a third of practices were against the inclusion of indicator 1. Staff identified three potential problems with the indicator: the time required to undertake the bio-psychosocial [BPS] assessment; recording and auditing issues; and concern that this formalisation could be unhelpful to the doctor-patient relationship.
One GP said: ‘I think you end up spending all your time asking the questions and not seeing how the patient really is’ (GP, Practice ID: 22).
The BPS assessment included 16 separate elements, 11 of which were seen by the pilots as routine practice e.g. asking about suicidal ideation. Concerns were expressed that if practices were asked to record each element of the assessment separately, that this could become a tick box exercise. This was balanced against other concerns that the first new indicator would be open to gaming if only a single overarching code was required. Personally I think clear QOF guidance and reliance on our professionalism as doctors should enable 99% of practices to find a way of working that feels comfortable to us all and, above all, our patients.
The second new indicator, on the other hand, was more straightforward according to our QOF pilots. Just over three quarters of practices were supportive of this indicator being included in QOF. The majority of practices felt that the time frame for review of 10-35 days was more reflective of their current clinical practice than the existing DEP7 and would be easier to implement.
A qualitative review of the patient was also felt to be more patient centred than the current DEP7. One GP told us: ‘They [patients] think I am more interested in the questionnaire than in their condition… so I think it would be better to remove that second PHQ9″ (GP, Practice ID: 10).
There was also a palpable sense of frustration from a small number of GPs on the Pulse website, such as one commenter who wondered, ‘Surely we can have a bigger say in QOF development?’. GPs should be aware that there are a number of ways that we involve frontline GPs at all stages of indicator development.
As soon as we have a new topic area from the NICE Advisory Committee (which includes 10 GPs), we run focus groups with frontline GPs to gain their views on the feasibility and necessity of our initial indicators and for them to suggest any modifications.
We then work with 30 practices for six months to put the modified pilot indicators into practice and give us detailed feedback including workload, coding issues, patient and practice acceptability. NICE also run a public consultation on all the potential QOF indicators.
However, we are always looking for new practices to work with. If there’s a practice out there who wants ‘a bigger say’ in developing and improving QOF indicators, then please contact me.
Professor Helen Lester is a GP in Birmingham, and a professor of primary care at Birmingham University.