How NICE is making its decisions on QOF

Having conducted its first meeting behind closed doors, NICE's independent QOF review committee opened its second hearing to the public last month.

Sat round a U-shaped table, the 29 committee members worked their way through more than 40 proposed changes to the QOF, making decisions swiftly and always by consensus, rather than vote.

All the discussions had the feel of a group keen to listen to all views, but also wanting to make decisions without lengthy debates for their own sake.

Committee chairman Dr Colin Hunter, an Aberdeen GP and honorary RCGP treasurer, would let a few members speak before stepping in and attempting a decision.

Discussions moved from correcting wording to talks about what the QOF was really for and how it should develop.

The overarching issue returned to often was whether indicators should be aggregated, so that there are fewer in any given area, or unbundled, so that each point addresses a separate clinical issue.

After a lively discussion of the benefits of either approach, the committee decided it would be sensible to have consistency across the framework on this and will decide on a guiding principle at its June meeting.

The committee found itself having to differentiate between things that needed to be included in QOF, things that were good ideas and things that GPs should do. Dr Hunter talked about the issue as needing to 'think with my QOF hat on'.

Diabetes and falls
The committee discussed, for instance, what the point would be of including an indicator for referral to a type-2 diabetes education service if no such service were available locally. Patient outcomes would not be improved and GPs would be paid for doing no work if there were no services.

For falls assessments, many practices cannot access an appropriate service and may not be responsible for all referrals.

Dr Hunter said the issue came down to the more general question of what GPs' approach to falls should be. That was something that needed looking into, but it was not, he said, the business of the QOF committee.

Unsurprisingly, some indicators were deemed more worthy of consideration than others.

Rejection of a proposal to include a register of undernourished diabetes patients was deemed a 'no brainer' by Dr Hunter if patients already have their BMI registered.

But a proposal to include the new as well as old HbA1c units in diabetes indicators was pushed through immediately and, though only a technical issue, is likely to be the only change in the QOF for 2010/11.

Although all the decisions were supported by consensus, the outcome of discussions often turned after one particular issue was raised.

Decisions would then move from being put into progression to being put on hold, or vice versa, losing, in a minuted agenda item, all the subtleties and nuances of the debate around the committee room.

The next QOF meeting is in Manchester on 3 June. Registration will be open from 14 May at www.nice.org.uk.

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