CCGs urged to fund epilepsy GPSI service to replace 'failed' QOF indicators

Commissioners should fund additional GPSI-run epilepsy services in the community to address shortcomings in care following the scrapping of QOF indicators for the condition, according to a GP expert.

A brain MRI of an epilepsy patient: researchers called for GPSI-led services to plug gaps in care (Photo: SPL)
A brain MRI of an epilepsy patient: researchers called for GPSI-led services to plug gaps in care (Photo: SPL)

QOF raised annual review rates but 'failed to deliver its optimum potential' for epilepsy care in the UK, which still has significant shortcomings, said Dr Ian Minshall, a GPSI in epilepsy based in Cheshire.

His study, published in the journal Seizure, reviewed the case notes of over 500 people on anti-epilepsy drugs and found problems with prescriptions, a lack of shared care arrangements and insufficient pre-conception counselling. In some cases there were significant doubts over the original diagnosis.

Co-authors Dr Minshall and Aidan Neligan from University College London argued in the paper that a separate GPSI-led service was needed to address these issues. They warned CCGs that failing to invest could see the quality of care fall further behind.

Dr Minshall has contacted his local CCG in a bid to establish a part-time GPSI-led service. He told GP:  'Epilepsy is a complex illness, with multiple causes and presentations. A GP may not have enough expertise to manage people with epilepsy either acutely or chronically.

'The condition requires specialist knowledge to diagnose and classify and hence prescribe, plus address other issues such side-effects, compliance, misdiagnosis, poor control, long-term remission, bone health, contraception, pre-conception and mental health.

'I would argue most of these could be dealt with by a GPSI and an epilepsy nurse specialist working in a CCG, along with the person’s GP.'

Targets scrapped

Four epilepsy indicators were introduced in the first year of QOF in 2004 under the new GP contract. These required GPs to hold a register of patients, record seizure frequency, review medication and calculate the proportion who were seizure-free in the past year.

These were amended in subsequent years - most notably an indicator to give information and counselling about contraception, conception and pregnancy to women under 55 - before all but the register target were scrapped in the 2014/15 QOF.

Dr Minshall's study found the vast majority, around 93-96% of 540 epilepsy patients from 13 GP practices, had an annual review in 2007/8 or 2008/9.

But despite the presence of medication reviews in the QOF, 13% of patients had 'anomalies' in their prescriptions, from inappropriate dosing to low dosages below usual therapeutic levels.

Although a fifth of patients were seizure-free for longer than 10 years, only 6% of these patients' records showed evidence of a discussion about withdrawing anti-epileptic drugs.

Doubts over diagnoses

Of the 150 people (28%) with poorly controlled epilepsy, half (49%) did not have shared care agreements. Among 98 women of childbearing age, 21% had not received pre-conceptual counselling and only 38% received a regular folic acid prescription.

While 71% of women with epilepsy were prescribed an anti-epileptic drug known to affect bone health for 10 years or more, none received vitamin D supplements.

In addition, there was 'significant diagnostic doubt' about the original diagnosis in 5% of patients in the study.

Authors said the similarity between the proportion of patients on shared care agreements in the study and earlier figures suggested QOF 'has not had an impact on referral rates to secondary care'.

Study authors said the removal of most epilepsy QOF indicators will reduce GP reviews 'significantly'. 'Now is the time for CCGs... to consider the future provision of care for people with epilepsy in the community and with that comes the potential to review alternative treatment paradigms in primary care,' they argued.

Epilepsy QOF indicators 'failed'

They added: 'In our opinion, QOF failed to deliver its optimum potential of improving primary care management of people with epilepsy. Despite this, it is clear that QOF has resulted in significant improvement in annual review rates whilst highlighting unmet needs in care.

'Those deficiencies need to be addressed medically and financially more effectively. This will require investment by CCGs now, before we miss another opportunity.'

NICE currently recommends that all children, young people and adults with epilepsy should have a regular structured review. This should be at least yearly for children and young people and carried out by a specialist, while adults can be seen by a GP instead, depending on how well the condition is controlled.

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