The indicators on depression should be reviewed and improved, but removing them from the QOF would be a grave mistake, says Dr Alan Cohen.
Last month, NICE published its final recommendations for changes to the QOF, which are to be negotiated between NHS Employers (on behalf of the Department of Health) and the BMA.
Among its recommendations, it advised that the three depression indicators should be dropped. These are: DEP01, case finding for depression among people on the diabetes or the cardiovascular disease registers; DEP02, assessing the severity of depression for patients with a new diagnosis of the condition; and DEP03, carrying out a further assessment of severity within 12 weeks of the initial assessment.
NICE argued that there is a lack of evidence that these specific indicators have been successful in treating depression and achieving better outcomes for patients, and that GPs have raised concerns they were overly bureaucratic. Confusingly, NICE guidelines CG90, CG91 and CG123 all provide the evidence – the evidence that is said to be lacking – alongside recommendations for implementation in routine practice. The three indicators were designed to implement NICE recommendations. The Improving Access to Psychological Therapies programme in England has provided extensive evidence that a stepped-care approach to depression produces improved outcomes.
The recommendation to drop the depression indicators, rather than replace them with alternatives, has proved controversial. It is perhaps particularly surprising as, in its own guidance for 2011/12, NICE highlights the huge impact that depression alone has on the UK economy. It cites, in 2000, 109.7 million lost working days and 2,615 deaths attributed to depression. The total annual cost of adult depression in England has been estimated at over £9bn, of which £370m represents direct treatment costs.
I have real concerns that removing these indicators will give the wrong message about depression, especially given the prevalence in primary care and the increasing number of antidepressant prescriptions written each year in the UK.
All practices are under enormous pressure to deliver a wide range of services. While I accept the current depression indicators are far from perfect, removing them completely (and their 53 points) runs the risk of a diminution of interest within some practices in addressing depression in a planned and structured way.
Improvement, not removal
Across England, the statistics show a relatively low achievement rate on the three depression indicators relative to most QOF indicators.1 In 2009/10, for DEP01 it was 92.7%, for DEP02, 92.1%, and for DEP03, a very low 64.4% – suggesting some real issues for GPs in meeting this particular indicator.
But it should be remembered that the QOF was introduced to provide a financial incentive to deliver high-quality, essential services. To remove the depression domain implies that treating people with depression is not part of essential services, and that message is unacceptable.
Clearly, the indicators should be reviewed and improved, as with all domains and indicators. They need to be both evidence based in terms of helping to address depression in primary care and leading to better patient outcomes, and also backed by all GPs as achievable.
But removing them without suitable alternatives strikes me as irresponsible. Depression creates a huge burden on individuals, communities and society as a whole – as well as placing significant pressure on GPs, who will generally be the first port of call for support.
Depression must not be sidelined, as could happen if QOF loses its depression indicators. Any lessening of the focus on depression would be wrong. It is an issue that has an impact on all areas of society, from a personal level to a cost to the UK economy of billions of pounds every year.
Dr Alan Cohen is a GP in Wimbledon, south-west London, and was formerly national primary care lead for the Improving Access to Psychological Therapies programme
1 NHS Information Centre, QOF tables for April 2009 to May 2010, England