Controversial QOF proposal by NICE risks worsening care

A controversial new eight-in-one bundled QOF indicator for diabetes could endanger patient care rather than improve it, a senior GP has warned, as NICE formally proposed its QOF 'menu' for the 2015/16 contract.

Diabetes: GP leaders warn new QOF proposals could disadvantage hard-to-reach patients (Photo: iStock)
Diabetes: GP leaders warn new QOF proposals could disadvantage hard-to-reach patients (Photo: iStock)

NICE announced on Friday that the measure will be included on its 'menu' of new indicators to be considered by negotiators for next year's GP contract. It was approved despite most GPs opposing the plan and warnings from diabetes GPSIs that it could ‘interfere’ with the patient-doctor relationship.

The measure would see practices forced to complete all eight separate diabetes checks, from cholesterol to foot examination, to receive income for just one QOF indicator.

Dr Andrew Green, chairman of the GPC's clinical and prescribing subcommittee, told GP there was a 'real danger' the indicator could 'lower rather than increase care'.

NICE has insisted the measure would set ‘high standards of care’ and improve outcomes for patients.

Hard-to-reach communities 'at risk'

Dr Green said bundling the indicator could perversely incentivise GPs not to help patients in hard-to-reach communities, who may be less likely to return to the practice for further tests or hand in the required urine samples. This would effectively penalise practices for factors outside of their control.

NICE's controversial new diabetes QOF indicator

The percentage of patients with diabetes who have had the following care processes performed in the preceding 12 months:

  • BMI measurement

  • BP measurement

  • HbA1c measurement

  • Cholesterol measurement

  • Record of smoking status

  • Foot examination

  • Albumin: creatinine ratio

  • Serum creatinine measurement

He said: ‘The danger is that practices will provide care to the patients that are easy to reach, but not be incentivised to provide care where they know they won't get all the indicators.

‘What's the incentive to me to do all that I can for that patient if I know no matter how hard I try I won't get that last indicator?

‘The net result of this is to reduce the amount of money that practices have to provide care for diabetic patients, and so there's a real danger it will lower rather than increase care.’

The warning strengthens the GPC's stance on the proposal. Chairman Dr Chaand Nagpaul had previously said the move would be 'counterproductive', after a GP survey found two-thirds (64%) of the profession rejected the idea.

New hypertension checks proposed

NICE has also proposed three new hypertension indicators to incentivise tests for urinary albumin:creatinine ratio, haematuria and 12-lead ECG within three months of diagnosis. These also come with the option to bundle them into one.

In addition, an indicator to offer advice on contraception, conception and pregnancy to women with various forms of psychosis has been added to the menu, in spite of very low support from the practices which piloted it.

Changes to several existing indicators were also proposed, to reflect changes in the underpinning NICE guidance.

AF indicator AF004 was proposed for retirement, following advice that strongly recommended aspirin should no longer be offered for stroke prevention.

Proposals 'set high standards'

Professor Gillian Leng, deputy chief executive at NICE, said the new indicators would help set ‘high standards of care’ and improve outcomes for patients.

She said: ‘All of the indicators are based on the best evidence and have been developed in consultation with professional groups, patients and community and voluntary organisations. They have also been tested across general practice to make sure they work.'

Aberdeen GP Dr Colin Hunter, chairman of the QOF advisory committee, said: ‘We believe that the indicators we’ve put forward on today’s menu will improve the care that GPs provide for their patients.’

The committee said different variations of the bundled diabetes indicator could be considered by negotiators ‘where incentivisation of a smaller subset of care processes may be more appropriate’.

It confirmed that conducting seven tests, without a foot examination, would be a ‘valid exception’ in cases where a patient had had both feet amputated.

The decision on which of the indicators will be included in the 2015/16 QOF will be agreed over the coming months in negotiations between the GPC and the governments in England, Northern Ireland, Scotland and Wales.

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