National Institute for Health and Care Excellence
NICE Indicators Consultation
Closing date: 5pm – 23rd February 2015
Whalebridge Practice, Swindon and QOF Database Website (http://www.gpcontract.co.uk)
Title (e.g. Dr, Mr, Ms, Prof)
Job title or role
GP and website owner (QOF Database http://www.gpcontract.co.uk )
Address and post code
The Whalebridge Practice, Swindon Health Centre, Carfax Street, Swindon, SN4 0EN
Please note: comments submitted on draft indicators are published on the NICE website.
The personal data submitted on this form will be used by the National Institute for Health and Care Excellence (NICE) for the purpose specified. The information will not be passed to any other third party and will be held in accordance with the Data Protection Act 1998.
Please provide comments on the draft indicators on the form below, putting each new comment in a new row. Please note the indicator or measure that you are commenting on in the ‘ID’ column.
In order to guide your comments, please refer to the general points for consideration on the NICE website as well as the specific questions detailed within the consultation paper.
Please add rows as necessary.
Indicator / measure ID
QOF IND 1
Whilst the identification of CVD risk factors in patients with severe mental health problems is of commendable principle it is not clear whether there are appropriate and evidence based interventions available. The argument that severe mental health problems is a risk factor in itself is made in the consultation document and is persuasive. However the indicator relates only to the documentation of this rather than the treatment.
An indicator about appropriate intervention may be more valuable and credible.
QOF IND 2
Again this illustrates a problem with QOF in that it may be seen more as a data gathering exercise. In many cases the presence or absence of obesity is clear when a patient is seen in a consultation. What this indicator will add is a weight measurement in cases where both the doctor and the patient know that there is no problem. It will simply become a formality “for the computer”.
The same is true where obesity is present, although this is currently incentivised through the obesity register. The readout on a scale is seldom a surprise to either person.
As an aside this would effectively add an osteoarthritis register to the QOF.
QOF IND 3
I have to admit that I found the text around this indicator difficult to understand. I don’t understand the phrase “may help to detect any differential effect upon immunisation coverage”.
The current situation is that there is effectively a higher payment for patients with multimorbidity. This indicator would reverse that and each vaccination would attract the same payment whatever the patient’s level of risk. Is this the intention?
QOF IND 4
A register of patients who are housebound or in a nursing home is not a bad idea although the point that there is no definition of “housebound” is well made. There are likely to be significant variations between practices in that definition.
I have also known many patients in residential homes who are not housebound and regularly go out on trips!
It may be simpler to drop the “housebound” category. Nursing home status is already recorded as part of the registration process and is used in the calculation of the Global Sum. Would this be picked up by QOF searches? (it is not read coded)
Residential home status or sheltered housing could be added to this.
What is not clear is how this would interact with the Admission Avoidance DES register (although the DES is outside the remit of NICE). We could be left with two different definitions of vulnerability which may be less than helpful in directing resources appropriately.
QOF IND 5
Medication review was removed from QOF a couple of years ago with the general demise of the Organisational domain. There should be little problem with this.
There is no need for a face-to-face review. As this will be away from the surgery (by definition) there will be less information available for the review to take into account such as blood test and clinic letters. Whilst an annual review face-to-face review of these patients is appropriate decisions on medication may be more appropriately made with full access to their records.
QOF IND 6 and
QOF IND 7
Psychological therapies are important. However in my area at least there is open access to these therapies and a referral is not required. I would suggest the wording is changed to purely document the offer of psychological therapies without specifically mentioning a referral.
There is a strong overlap between anxiety and depression and separate indicators are likely to produce an artificial distinction. Many patients are diagnosed as “anxiety with depression” - would these patients appear in both indicators or just one, and if only one which one? I would suggest that these indicators are merged.
QOF IND 8 and
QOF IND 9
The use of the QRISK2 formula for patients with newly diagnosed hypertension was previously a QOF indicator until a couple of years ago when it was withdrawn. It worked well and there is no particular reason why it should not return. Similarly there is no reason not to extend this to patients newly diagnosed with diabetes. There will be few patients with diabetes who will not meet the 10% threshold.
The NICE guideline is unhelpful in its suggestion that high risk groups are determined before a full assessment without specifying this in more detail. Playing around with the formula suggests that it couple be worth screening all smokers over 50 years of age but a full assessment of whether this met the criteria for screening would be required and is likely outside the scope of this committee or consultation.
QOF IND 10 and
QOF IND 11
The problems with these indicators is well highlighted in the consultation document. These indicators specifically refer to patients in whom a new diagnosis is made in the previous year (in reality exception reporting requirements are likely to extend this to around fifteen months).
If lifestyle intervention is to be first line (and this is appropriate in patients with a relatively low risk and hence low benefit) then this is most likely to be in the first six to nine months after diagnosis. Lifestyle changes take some time to show their benefit. Some patients will be little more than three months after diagnosis when lifestyle interventions should still be working their way through to blood tests or BP readings.
The indicators could be reworded to specify any intervention - whether lifestyle or pharmaceutical. Alternatively it could be changed to look at any year other than the one of diagnosis.
It should also be noted that, although the NICE guidance is currently 10% risk threshold, this remains controversial amongst practicing clinicians.
QOF IND 12
A register of patients with 10% risk would be interesting but it is not clear what purpose this would be expected to serve. QOF registers are simply a list on a screen of the result of a search. This data would already be on the computer. There would be an incentive to increase this number to add to prevalence (if this had its own area) but the number of points allocated would have to be relatively high to incentivise this.
Closing date: Please forward this electronically by 5pm on 23rd February 2015 at the very latest to firstname.lastname@example.org
PLEASE NOTE: The Institute reserves the right to summarise and edit comments received during consultations, or not to publish them at all, where in the reasonable opinion of the Institute, the comments are voluminous, publication would be unlawful or publication would be otherwise inappropriate.