Going out?

The QOF advisory committee also looked at indicators that might be removed. This makes sense as there is no point in suggesting new areas without trying to free up some cash to pay for them. You can read the full details in the minutes but I will give a summary here.

This was split into two areas. As nobody really knows what happens to service delivery when an indicator is removed they were classified as low risk and higher risk. The low risk areas were:

• CHD 5, Stroke 5 and DM 11 - The measurement of blood pressure in coronary heart disease, stroke/TIA and diabetes.
• DM 5 - The recording of HbA1c in diabetes
• DM 16 - The recording of cholesterol in diabetes

You may have spotted a theme here. These are all about the recording of measurements, or to use the NICE jargon, process indicators. They do not represent outcome. They all have matched outcome indicators. The outcome indicators are not quite a perfect match, of course. Outcome indicators have a much longer exception time after diagnosis or registration (9 months) than the process indicators (three months). They are also much more likely to be affected by other exception reasons such as patient preference for medications and patients having maximum tolerated therapy.

The QOF committee does not currently deal with either the points value of indicators or the thresholds, which is a pity. The effective indicator only works as a combination of criteria, thresholds and points and any division into parts is likely to miss some aspects of the whole. What we can say is that simple removal of these areas would represent a disinvestment in these areas. The degree varies by area. In diabetes the process indicators tend to be about a quarter of the value of the outcomes. The loss of these process indicators is in total about £5 per patient with diabetes. The figures for CHD and stroke are £4.30 and £2.64 respectively (these figures are for the whole register- the amount you gain or lose by performing a blood pressure on a patient already on the register, within the thresholds would be double these figures). To put it another way these indicators are worth £2,282 for an average practice in England.

It is possible to overstate the effects of these losses but there is now no incentive payment for measuring blood pressure in patients unlikely to hit the outcome targets - the patients most at risk.

The committee also suggest three indicators for removal which they state have a higher level of risk.

• DM 22 - eGFR or creatinine testing in patients with diabetes.
• MH 4 - Creatinine and TSH testing in patients on lithium
• Thyroid 2 - Checking TSH in patients on thyroxine - the committee also noted this would leave Thyroid 1 (the register) on its own with no other indicators. They did not actually write "so what would be the point?" but I'm sure I heard them in my head.

Diabetes would still require enough blood tests that the renal function box is virtually bound to be ticked at some point. It was, however, at least a nod to the importance of renal function in diabetes, especially in patients taking metformin.

I am no psychiatrist but lithium certainly seems to be yesterday's drug these days. Around 5% of practices have no patients at all taking lithium. I personally would drop all the lithium indicators.

There really does seem to be little point in keeping the thyroid register if the indicator goes. It is automatically generated. Could we see the first clinical area to be dropped from QOF since its introduction?

Next time - the possibility of changing the thresholds.