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Monitoring diabetes in QOF

Monitoring diabetes in QOF
4 September 2013

The number of points available for diabetes has risen, making it essential for GPs and practices to manage this condition as effectively as they can
Diabetes has a huge potential effect on the future health of our patients. It has been part of the quality and outcomes framework (QOF) since the very start and was even used as the example when the new general medical services (GMS) contract was first being presented.

The number of points available for diabetes has risen, making it essential for GPs and practices to manage this condition as effectively as they can
Diabetes has a huge potential effect on the future health of our patients. It has been part of the quality and outcomes framework (QOF) since the very start and was even used as the example when the new general medical services (GMS) contract was first being presented.
It was attractive to the designers of the QOF as there are clearly defined processes and targets which lend themselves to the structure of the indicators. Since then the profile of diabetes has only gone up. Across the UK there were 50% more patients diagnosed with diabetes in 2012 than there were in the 2005. This year there are 107 points available (99 in 2005), which is nearly 12% of the whole QOF. The prevalence formula means that practices receive, on average, a quarter less cash for each patient with diabetes than they did in the first year of the QOF.
Although the National Diabetes Audit (NDA) preceded the QOF, it has risen to greater prominence over the last couple of years. One of its major indicators, the presence of nine processes, has had particular relevance for GPs and is also a major method of judging the progress of clinical commissioning groups (CCGs). The markedly different results from the QOF and the NDA, largely due to differing codes and clinical criteria, have exasperated statisticians and NHS management alike.
Against that background it is a little surprising that two of these processes have been removed from the QOF this year. The indicators measuring the recording of body mass index (BMI) and taking blood to measure renal function have been retired from April 2013. It is expected that practices will continue to perform these tests. There will still be some advantage to the practice where patients are obese – a measured BMI of over 30 will put the patient onto the obesity register. Increasing obesity prevalence rate in this way will attract a small payment for each patient.
Similarly, blood results for glucose control, via HbA1c measurement, and for blood cholesterol analysis will still be examined. Measurement of renal function usually requires no further sampling and will simply be another tick on the form. Many patients will be taking ACE inhibitors or similar drugs and need the test in any case. It is for these sort of reasons that the National Institute for Health and Care Excellence (NICE) advisory committee suggested that they could be successfully removed from QOF. It is expected that practices will continue most of the work without this income, the definition of efficiency.
One small change brings the QOF more in line with the diabetes audit. Since the start of QOF, one indicator has concerned testing urine for microalbuminuria. Up until this year it has been acceptable to test urine using special dipsticks in the surgery. For several years this has not been the recommendation from NICE or the national audit criteria. From this year only laboratory testing for albumin to creatinine ratios will be acceptable for this indicator.
The majority (59) of the points are still for surrogate outcomes of diabetes care. This is about treatment to targets for cholesterol, blood sugar and blood pressure measurements. None of these measurements are the ultimate aim of treatment – the reduction of life impairing complications and death. These surrogate measures are easier to measure and use for practice payments. Their use is not without controversy. Two years ago the lowest threshold for blood sugar control was raised when it became apparent that it may be causing patients harm. There are similar discussions about the tight control of blood pressure. The pros and cons of adherence to the targets will vary from one patient to another and clinical judgement will need to be exercised for each patient. The new indicators this year do not reflect any of the key processes specified in the NDA. Interestingly they do consist entirely of processes rather than outcomes – finding easily measurable and evidence-based outcomes is hard.
The simplest of these indicators is for the referral of patients newly diagnosed with diabetes to a structured education programme. There are a variety of such courses available and this is a fairly well rewarded area.
The referral must be made within nine months of the diagnosis of diabetes being made, although the actual date of attendance at the course may be later.
The ability to refer to such a course will depend on it being available locally. In the initial consultation there were similar indicators for referral to courses and classes in chronic obstructive airways disease and heart failure. In these two cases the introduction of the indicators was postponed due the lack of local availability. Only the diabetes indicator survived.
The official guidance is clear that patients may be exception reported if a course is not available or if the patient does not want to attend it. However if all patients are excepted then they will attract no points. Practices are expected to apply pressure through their CCGs to provide courses that are accessible to patients. This may include patient transport to get patients there although immobility is likely to be less common than in patients with chronic obstruction pulmonary disease (COPD) or heart failure. CCGs may decide to commission the courses directly from the practices themselves, which may improve access for patients. As long as services are available for referral before the end of the QOF year, practices should be able to get the available points. This is financially worthwhile, with eleven points available for the referral of a relatively small number of patients.
More controversial has been an indicator rewarding the giving of dietary advice to patients with diabetes. Diet is a crucial part of the treatment of diabetes and there is even some evidence that early dietary measures can resolve diabetes, at least temporarily. This indicator has been implemented in slightly different ways around the UK. In England the guidance for what such a review should cover stretches to over a page. The regulations also state that the advice should be from a suitably qualified professional. In practice, the level of knowledge required is level one of the Diabetes UK dietician guidelines. These are a pretty low bar and all GPs and a large majority of practice nurse will exceed this.
Part of the contract deal in Scotland was that GPs will explicitly be acknowledged as having the skills to deliver the dietary review. However there are only three points available for doing it and a lot of patients who have diabetes. The top threshold is 90%. On average this will be worth around £1.50 per patient which will not pay for a lot of time. This would pay for just over a minute of practice nurse time or even less time with GP based on the NICE recommended costings.
Erectile dysfunction has also been added to the QOF with two indicators around enquiring about erectile dysfunction. Diabetes is one of the commonest physiological causes of erectile dysfunction in the UK. It is the most common reason for prescribing of erectile dysfunction drugs on the NHS. The NHS has had an odd relationship with erectile dysfunction treatment. Prior to 1999 the only available drug treatments involved injection into the penis. Other physical options were available but were also generally unattractive.
It was anticipated that demand for treatment would increase when oral therapy became available and so, uniquely, NHS treatment was restricted to patients with either diabetes, pelvic injury or various neurological diseases. Diabetes patients are also exempt from the standard NHS prescription charge in England.
Inevitably the screening for erectile dysfunction will increase NHS prescribing. It may be a huge coincidence but the introduction into QOF comes at about the same time as the expiry of the Sildenafil patent this summer. The drug treatment of erectile dysfunction is likely to be a lot less expensive this year than last.
All male patients on the diabetes register will need to be asked if they have erectile problems and have the answer recorded. There is no upper age limit but the register only records patients eighteen years or older. As this is measured at the end of the QOF year some patients may need to be asked when they are still seventeen years old.
If problems are recorded then there should be an assessment of causes (the effects of diabetes are likely to be the major cause in most cases) and the potential for treatment. While lifestyle advice including weight loss and increase in physical activity can play some part, most of the treatment is likely to be with oral medication if there are no contra-indications. 
Apart from the new indicators, diabetes has been more affected by increases in thresholds than any other disease area. It is here that variation between the four countries becomes relevant. This is also likely to be the most challenging change for many practices.
The changes to the thresholds are mainly in the outcomes indicators, that is the three blood sugar control (HbA1c) indicators and the two blood pressure target indicators. The final two areas are the prescription of ACE inhibitors or angiotensin antagonists to patients with have microalbuminuria and giving of flu vaccinations.  
Each of the four countries has taken a different view on how to set these thresholds. As an example to the top threshold for the prescriptions of ACE inhibitors has risen from 80% to 97% in England (with a starting threshold of 57%). In Scotland the upper figure is 90% with a lower threshold of 50% and in Wales the figures are 91% and 51%. These are steep rises throughout the UK but England has been hit hardest. This variation occurs in all of these seven indicators and will likely extend across the whole of the QOF from 2014. Practices may find that room for discretion has been reduced and more efficient exception reporting will be required. There has been such a focus on diabetes as a treatable long-term condition practices feel under pressure from a variety of directions. Differing national criteria in the QOF and NDA can cause confusion and local priorities from CCGs may further muddy the waters.
Practices need to have a clear strategy for which areas they plan to concentrate on and how they will achieve this. Thresholds have risen to the degree where only the best organised practices will achieve high numbers of points and it is likely that they will rise further over the coming years.
Diabetes remains a large area of QOF but also an area which can have a large long-term influence on patient health. Practices have proven efficient at identifying and treating patients with diabetes. While not all of the new indicators are individually financially worthwhile this will remain one of the key areas of effort.

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