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NICE work: potential QOF changes from March 2012

NICE work: potential QOF changes from March 2012
31 August 2011

You may not have noticed but the way that new Quality and Outcome Framework (QOF) indicators are developed has changed. Originally the indicators were produced in private by committee, passed to the negotiators and then announced to the world.

For the last two years the process has been taken over by the National Institute for Health and Clinical Excellence (NICE) and its QOF Advisory Committee. Under this new system the process is much more open and conspicuously evidence based.

You may not have noticed but the way that new Quality and Outcome Framework (QOF) indicators are developed has changed. Originally the indicators were produced in private by committee, passed to the negotiators and then announced to the world.

For the last two years the process has been taken over by the National Institute for Health and Clinical Excellence (NICE) and its QOF Advisory Committee. Under this new system the process is much more open and conspicuously evidence based.

Each potential new indicator has been piloted in a selection of practices and is appraised by a NICE committee. Their meetings take place largely in public and the menu of indicators presented to the negotiators is published in advance.

This has been a gradual takeover. Next year will be the first set of indicators that have been through the process from start to finish and there is certainly a sense that the committee is developing its own style and policies, which are reflected in the indicators.

The negotiators can still surprise – the quality practice indicators came out of the blue – but the menu of indicators gives some idea of what might be coming.

A word of caution, however. Not all of the menu is likely to be accepted and certainly none of these will apply in this QOF year. Nevertheless, forewarned is forearmed and where indicators are accepted they may apply from 1 January 2012. As negotiations this year did not conclude until late March there is significant potential to get ahead of the game.

It is highly unlikely that extra points will be added to the QOF over the 1,000 currently. The advisory committee has recommended several indicators for retirement, which will free up points for new indicators. The negotiators may also slice a few points from other indicators so be reallocated.

This article will briefly look at what is proposed for retirement, but remember that you will need to keep working towards these until March 2012.

Out with the old
The committee found little evidence for any of the depression indicators and all are marked for removal – freeing up 51 points. If they do stay then changes are suggested to the second depression assessment so that it can be within two weeks of the first assessment and will still count even if the first assessment is missed.

Several measurement indicators are marked for retirement, a process that started this year. Blood pressure measurement in hypertension (BP4) and chronic kidney disease (CKD2) are out as is the measurement of cholesterol in stroke (Stroke 7).

In these cases the achievement indicator for correct levels remains. BMI and estimate glomerular filtration rate measurment in diabetes (DM2 and 22) and seizure frequency in epilepsy (Epilepsy 6) are also marked to go.

CHD 13 – the referral of all new patients with angina to secondary care – is to be retired in line with NICE guidelines, although if it stays it will be modified to only look at the current QOF year.

TSH in thyroid disease (Thyroid 2) also offered its P45. This would leave the thyroid area empty and, although not explicitly stated, it seems likely that the thyroid register (Thyroid 1) would also go.

If all these were withdrawn 111 points would be released. If some remain for political reasons then there may be few points to reallocate.

In with the new
The quality practice (QP) indicators were brought in for 2011/12 with a plan for review at mid-year. Officially they have to prove themselves to deliver savings at that stage to be carried on until next year. There is simply not enough evidence to assess the effects at this stage and I would expect these to be continued into 2012/13.

It is now health department policy that public health should make up 10% of QOF, currently 100 points. There are already several public health indicators in QOF, particularly related to smoking.

It is suggested that there should be an indicator measuring advice given to all smokers whether they have a chronic disease or not. This would be part of the Records section. Given the pressure for public health indicators this seems very likely to make it to next year's QOF. As the proposed indicator would look back over 27 months, work coded now (8CAL) would apply to the first year and it would certainly do no harm to encourage this.

A proposed addition to the current primary prevention indicators – dealing with new cases of hypertension – is an assessment of physical activity with the GPPAQ tool.(1) This should not be confused with the practice survey questionnaire of similar name. It is a series of questions about occupational and leisure activity. Generating a score from the result is a little fiddly however and its implementation may be tricky without good IT support. It remains to be seen how the negotiators view this.

The same area already includes a 10-year risk assessment using QRISK2 or similar assessment. Current NICE recommendations are for the use of a statin where the risk of a cardiac event is greater than 20% over 10 years. It is proposed that the subsequent treatment is included in the risk assessment indicator.

Changes are proposed in atrial fibrillation. While the ECG requirement is removed, a brace of indicators are introduced requiring the recording of a CHADS2 score and the use of anticoagulants in patients who have a score of one or more. As you can see it will be a rare patient who scores zero.

This is to be implemented in a rather peculiar way. All patients will require a CHADS2 score in 2012/13 and in subsequent years it is suggested that only new diagnoses will require coding. Scoring prior to next year will not be counted although this oddity may be changed at negotiation.


Box 1. CHADS score

Congestive Heart Failure         1 point
Hypertension                         1 point
Age ≥ 75 years                      1 point
Diabetes                                1 point
Previous Stroke or TIA            2 points

On the subject of more formal assessments, it is proposed that asthma reviews should incorporate the three questions from the Royal College of Physicians.


Box 2. The RCP (Royal College of Physicians) Three Questions for Asthma Review

1.    In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms)?
2.    Have you had your usual asthma symptoms (eg, cough, wheeze, chest tightness, shortness of breath) during the day?
3.    Has your asthma interfered with your usual daily activities (eg, school, work, housework)?


This would replace the current annual review indicator but it would be reasonable to use these immediately as they would certainly also fulfill the current criteria. The specific code for a review using the questions (66Yp) is not valid for the current review indicator and your current code should be used as well.

In a similar vein there is more structure to the treatment of diabetes. For new patients a new indicator would require referral to a structured education programme such as DESMOND or DAFNE within nine months of diagnosis.

If adopted this would be technically awkward to implement with some of the same problems around year ends that currently affect the depression indicators. A large number of practices do not currently have access to these services and practical implementation could also have problems.

A second diabetes indicator applies to all patients with diabetes and will require a dietary review in the 15 months of the QOF year. The catch here is that the review should be undertaken by a suitably competent professional. It is clear from the associated documents that GPs are not considered suitably competent. A specific course will need to be undertaken by doctors or nurses to become competent.

While demand from a large number of practices will increase the availability of courses, this could still be a barrier to implementation. As training and workload demands are likely to be high in this area it may take a considerable number of points to make this indicator viable to practices.

An entirely new area is proposed with the inclusion of peripheral arterial disease. The menu includes a register indicator and indicators for the use of anticoagulants and for hitting targets for cholesterol and blood pressure levels.

This will be very similar to the current cardiovascular indicators for stroke and ischaemic heart disease although numbers may be lower here. Patients on the register will also be included in the smoking indicators in a similar way to patients with diabetes or coronary heart disease.

Over the last three years there has been a directed enhanced service (DES) for the assessment and treatment of osteoporosis in women who have had a fragility fracture. It is proposed that this is moved into the QOF with the significant expansion to include men also.

Three indicators are proposed splitting the patients into two groups. For patients between 50 and 74 years old, a DEXA assessment is required if they have had a fragility fracture. Treatment should be given if indicated by the scan. The second indicator applies to older patients who do not require the DEXA assessment and should be treated if they have had a fragility fracture.

It is to be hoped that negotiators can agree as early as possible the indicators that will be used next year. Many of these will apply from 1 January 2012 even if they are not agreed until March. Some of these indicators are relatively easy to adopt and, while not top priority this year, practices could make life that little bit easier.

1. Department of Health. The General Practice Physical Activity Questionnaire (GPPAQ). London: DH; 2006. Available from:

What's your view of the proposed QOF changes? Your comments (terms and conditions apply):

"A constant ratcheting up of workload; this can only be ameliorated by clinically disengaging from areas not targeted or no longer targeted" – Patrick Ryan, Havant

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