NICE approves eight-in-one diabetes QOF indicator despite GPs' warnings

NICE has approved a new QOF indicator that could see GPs paid only if they complete a comprehensive set of eight diabetes checks, despite warnings it is 'unreasonable' from practices that piloted the measure.

Foot examination: GPs face a large composite indicator for diabetes (Photo: iStock)
Foot examination: GPs face a large composite indicator for diabetes (Photo: iStock)

A debate on the new measure divided opinion among GPs at a meeting of NICE's independent QOF advisory committee in Manchester on Wednesday, yet was granted approval despite widespread concerns over how it would affect practice workload.

It will now pass onto NICE's 'menu of indicators', which is used by the GPC and NHS Employers to inform negotiations on the next GP contract.

The measure was first proposed by ministers in 2012 following criticism that too few patients are receiving all nine recommended checks, and was piloted by NICE in recent months.

A group of practices that piloted the measure were paid based on the proportion of diabetes patients who received checks for BMI, BP, HbA1c, cholesterol, albumin:creatinine ratio and serum creatinine, as well as had smoking status recorded and a foot examination every two years.

But half of these practices called the large composite indicator ‘unreasonable’, warning it could unfairly deny practices income if they missed just one part of the indicator or a patient refused to co-operate.

A divisive indicator

After a divisive debate, Dr Colin Hunter, chair of the advisory committee, said the indicator should be approved as an 'unbundled' measure.

However, he said the option to bundle the indicator together would be left as an option for negotiators. The GPC may come under pressure to agree to a composite indicator, given that it was initially proposed by ministers.

Dr Hunter said there could be health and cost benefits in keeping the indicator bundled together, but there were also benefits to separating it. He added that the aim of QOF was not to demotivate practices with unattainable goals.

There was further controversy at the meeting as the committee recommended an indicator offering women with serious mental health conditions advice and information on pregnancy and contraception, despite very low support from pilot practices. Just 28% backed the measure.

Pilot practices reported that such patients were ‘difficult to engage with’ and said the benefits of adding it to the QOF were ‘unconvincing’.

However, an advisor said GPs may think differently if they substituted 'hard to reach' for 'easy to ignore'.

Dr Hunter agreed and urged the advisors to push for the indicator to be added to the menu, saying they were an ‘important group to reach’. He suggested a threshold range of 50-80%.

Polypharmacy measure blocked

Meanwhile, the committee also approved an indicator that would see patients with newly-diagnosed hypertension given or referred for an ECG and have albumin:creatinine ratio and haematuria tests within three months of being added to the hypertension register.

NICE advisors approved these as three separate indicators, but again offered negotiators the option to bundle them into a single composite indicator.

The committee rejected a proposed polypharmacy indicator, which would have seen GPs meet annually with elderly patients who are prescribed 10 or more medications, after practices reported 'major problems' with the indicator in the pilot. They said it was incompatible with IT systems and added nothing new to existing practice.

An indicator for prescribing antibiotics and self-management strategies to COPD patients was also not carried forward, despite favourable reviews from pilot practices.

The committee decided there was insufficient clinical evidence to recommend the indicator, and said it advocated a ‘one-size-fits-all’ approach to patient care, which would have been inappropriate for many of the affected patients.

Two indicators for screening hypertensive patients for excessive alcohol consumption were also rejected.

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