The new QOF will mitigate previous concerns about it encouraging mismanagement of complex patients and its retention will aid practices’ business continuity. By Robin Hewings
In early 2018, Diabetes UK called on NHS England to retain the Quality and Outcomes Framework, which was then under review. We’re pleased that NHS England has decided to retain QOF in England (announced 31st January, 2019), with some changes to address previous flaws.
QOF has already driven significant improvements to diabetes care by improving achievement of treatment targets and data collection. It has led to substantial improvements in the number of diabetes patients achieving HbA1c, blood pressure and cholesterol targets, and has increased the number of newly diagnosed people with diabetes being offered structured education in England and Wales.
It has also incentivised primary care providers to collect data used in the National Diabetes Audit, which provides a robust evidence base for improving the quality of diabetes care, as well as highlighting variation and good practice across England.
Commissioners have been generally positive about the impact of QOF in improving access to data on the management of patients with long term conditions. This has allowed them to compare the performance of different practices and bring about investment in IT infrastructure in general practice.
However, QOF isn’t without its flaws, which motivated NHS England to conduct a two year review of the framework, published in 2018.
The review called for a significant refresh of QOF; the consensus in England being for evolution rather than a wholesale or partial abolition of the framework, with commissioners reporting that practices perceive the funding available through QOF as being necessary to business continuity, meaning there was little appetite for radical change.
Diabetes UK is pleased to see that QOF will be retained and evolve to become a more effective tool for driving improvements to the quality of diabetes care and the collection of data which is fundamental to evidence based improvements in care.
Management of complex patients
The key change to QOF in relation to diabetes will be to mitigate a previous criticism that practitioners were incentivised to get the balance wrong between the long-term risks of a high HbA1c and the short term risks of hypoglycaemia. This mismanagement of complex, frail patients had been identified by commissioners as a key weakness of the framework.
In the words of NHS England:
“The changes seek to address problems with the current ‘one size fits all’ approach: the potential over-treatment of frail patients and the under-treatment of patients without frailty. Intensive glucose lowering treatment of Type 2 diabetes in older people is of limited benefit and there is increasing evidence of harm, including severe hypoglycaemia and congestive heart failure, which outweighs potential benefits.”
Diabetes UK is pleased to see that QOF will be retained and evolve to become a more effective tool for driving improvements to the quality of diabetes care and the collection of data which is fundamental to evidence based improvements in care
In other words, QOF previously incentivised the overtreatment of patients to ensure they didn’t exceed their HbA1c target, which put them at increased risk of hypoglycaemia. In older patients, an episode of hypoglycaemia is more dangerous than having a blood glucose level marginally over target, as hypoglycaemia can lead to dizziness, confusion and unconsciousness, all of which could result in a fall which could cause serious harm to a frail, older person.
QOF tried to mitigate against this by incentivising a range of glucose targets, but these were not stratified to patient groups, meaning they risked rewarding under-treatment of younger patients who, unlike their older counterparts, are less detrimentally affected by hypoglycaemia but are at greater risk of long-term complications caused by high blood glucose levels.
The new QOF will address this issue by focusing on achievement of the lower glycaemic targets of 64 mmol/mol for younger patients, which will in turn reduce their risk of complications. We are pleased with this change as we believe it nuances indication of successful treatment, accounting for differences in the needs of different patients.
There are other changes for cholesterol and blood pressure that bring the indicators into line with National Institute for Health and Care Excellence guidance, and the retiring of an indicator on erectile dysfunction. Our main concern with the new QOF is that the overall number of QOF points specifically allocated to diabetes has fallen from 59 to 43, as part of a broader reduction in QOF points allocated to specific conditions.
We will monitor the impacts of this change. However, we are pleased that QOF will be retained by NHS England for the foreseeable future, and hope it will continue to drive improvements to the quality of diabetes care across England.
The retention and development of QOF should be welcome news for NHS commissioners. The new QOF will mitigate previous concerns about QOF encouraging mismanagement of complex patients, and its retention will aid practices’ business continuity, with the framework continuing to provide vital funding.
It also will continue to drive improvements to data collection, which was previously identified by commissioners as a key benefit of QOF.
Further details of the changes are available here.