Published 9 July 2020
Swindon GP and QOF expert Dr Gavin Jamie analyses NICE’s new proposals for new indicators on vaccinations, obesity and cancer
Very few indicators that have been suggested by NICE have made it into QOF over the past few years, but this time could be different.
Firstly, there is a commitment in this year’s contract changes to move childhood vaccinations to an item of service basis with additional threshold incentives in the QOF. NICE seems to be responding to this with a range of possible indicators. These tally with the national immunisation programme and so are likely to be nodded through (with the possible exception of the incentive for a single dose of MMR in five year olds). The MMR indicators may be introduced in the first year as only MMR has been moved to the new system so far.
There is no indication given by NICE about the likely thresholds or points values, although this year’s contract documentation suggests that the upper thresholds will be at least 90%.
The pertussis indicator in pregnancy, while well intentioned, will be difficult to implement in practice for the reasons that NICE mentions in the consultation. The stages of pregnancy are not particularly well coded in practice systems. Estimated dates of delivery can change throughout pregnancy and we would need to be careful to record pregnancies that finish due to miscarriage or termination. It is certainly not impossible but the complexity of implementation may not be regarded as worth it.
The cancer indicators are an attempt to update what is not a particularly effective part of the QOF. It is the range of the cancers that tends to present problems. Some patients are diagnosed with cancer and have intensive treatment or die rapidly without much primary care input. Other patients may have a minor operation under local anaesthetic to remove a skin growth that they have nearly forgotten about in a couple of months. Designing indicators that meet the needs of both of these groups is, at the very least, hard. The new indicators change the timescale or the content of the reviews. I suspect that these may not be a great improvement in practice, however.
The obesity indicator is probably some ‘kite flying’. Around 4.8 million patients had a diagnosis of obesity in 2018/19 and that may cause some issues in weight management clinics. The indicator wording from NICE seems to suggest that they would need referral every second year.
Unfortunately, due to the way QOF works, they would all need referral in the first year. As there is not a great deal of change in the BMI of individuals over time, the second year would be much quieter with further biennial waves of referrals. The obesity indicator for patients with diabetes or hypertension has an annual referral cycle and probably has a better chance of making into the QOF.
Dr Gavin Jamie is a GP in Swindon and runs the QOF Database website
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