NICE takes on quality and outcomes
pharmafile | June 19, 2009 | Feature | |Â Â GP, NICE, healthcare, qof, qualityÂ
Some developments at NICE, now celebrating its 10th birthday, may have passed you by. They have moved beyond their technology appraisal and clinical guideline role, for which they were established.
They have absorbed public health guidance, quietly taken over responsibility for ‘NHS Evidence’ in England, and also accepted responsibility for the British National Formulary (BNF) for the UK.
And from April this year, NICE also takes on responsibility for the Quality and Outcomes Framework (QOF) for general practice across the UK. But is such a monopoly good or bad?
NICE have got it wrong in the past and it would be arrogant to believe that this will not happen again. Interpretation of evidence is a question of judgement and it continues to evolve. It can be argued that you need to foster a variety of different opinions to allow robust debate and that NICE have a poor track record in being sufficiently timely and responsive. The removal of the contract to provide the much respected Drug and Therapeutics Bulletin (DTB) to doctors and pharmacists in England appears to have been a casualty of criticisms DTB had made of NICE. It is essential to retain such checks and balances.
So what of the QOF take over? QOF came into being in April 2004. Most of us would regard QOF as a successful development; it has assured a consistent level of provision of quality services in general practices, based on best evidence, and has provided good financial rewards. However, a National Audit Office report in 2008 suggested that QOF points had been achieved too easily without clear linkage to outcomes and that achievements against the criteria had been much greater than predicted at considerable unplanned expense. They recommended a direct link to cost-effectiveness.
More responsive
As a result of frequent renegotiation QOF has been more responsive than many of us had predicted and the targets have been changed and tweaked. An expert panel to formally review the QOF was appointed by the NHS Confederation on behalf of the Department of Health to make the first set of revisions of QOF for 2006.
From 2006 the NHS Employers (part of the NHS Confederation), working for the four UK governments as negotiators, and the General Practitioner Committee (GPC) of the BMA have got together annually to thrash out an agreement on future framework revisions based on recommendations of this panel.
What can NICE add to this? In October 2008 a consultation was launched by the Department of Health in England on proposals that NICE should in future be responsible for the QOF revisions. The stated intention by the government was to create a more independent process, to improve transparency and to ensure best use of the annual investment. These proposals have very rapidly been accepted and implemented: NICE does not have a reputation for such speed. By April 2009 NICE had already set up a Primary Care Quality and Outcome Framework Indicator Advisory Committee and appointed a GP chair and representatives from primary care, patients, commissioners and nurses. They had also agreed a contract with an external academic body to review all existing indicators and support the development of new indicators. This body is a group made up of National Primary Care Research and Development Centre at Manchester University, the York Health Economics Consortium and the Royal College of GPs. They will be responsible for ensuring cost-effectiveness, producing guidance on implementation, and piloting the new indicators.
The intention is that indicators can be proposed by ‘stakeholders’ on the NICE website. These are assessed by the academic group and once validated they are put forward to the NICE QOF Advisory Committee for consideration. Recommendations of the Committee are published on the website for all to see. The Committee then recommends a range of these evidence-based and cost-effective indicators to NHS Employers and the GPC to negotiate on which indicators will be retained. From proposal to incorporation should take approximately two years, assuming NICE can keep to the timetable. Using a rolling programme annual updates will be made.
A number of criticisms have been levelled at these new arrangements, most notably by the BMA. Probably the most important is that the system seems to be working so why make it more elaborate, cumbersome and bureaucratic? A riposte is that it needs to be more robust and clearly linked to NICE guidance and cost-effective provision of care. Is elaborate piloting strictly necessary as changes can be made annually, as has occurred previously, if necessary?
This has been likened to a rapid Plan Do Study Act (PDSA) cycle. Other criticisms are that the QOF will be too cost driven and that NICE does not have a good track record in avoiding political interference. Perhaps the most important challenge will be convincing GPs that the process is truly independent and it gaining credibility. Also, there is a proposal to allow local variations from 2012 but this seems perverse if it bypasses the system set up by NICE and allows post-code variation in care.
One final point is the lack of clarity around where Wales, Scotland and Northern Ireland fit into the scheme of things both in relation to NICE and QOF. For example, the revision of the system for QOF appears to have been driven by the Darzi Report in England (High Quality Care for All: Next Stage Review) and the consultation for reviewing QOF was managed by the Department of Health for England.
Our regionally devolved versions of the NHS are now very different from each other. This begs the further question of whether the QOF can continue to be an all-UK framework.
Dr Martin Duerden is medical director for Conwy and Denbighshire Local Health Boards, a GP in North Wales, and honorary senior lecturer at Cardiff University.
This article was first published in our sister publication Prescriber
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