They have moved beyond their technology appraisal and clinical ... has provided good financial rewards. ... Economics Consortium and the Royal College of.
Editorial
NICE’s Quality and Outcomes Framework role: good or bad? Martin Duerden BMedSci, MRCGP, DRCOG, DipTher, DPH ome developments in the National Institute for Health and Clinical Excellence (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, absorbed public health guidance, have quietly taken over responsibility for ‘NHS evidence’ in England, and have also accepted responsibility for the BNF for the UK. The arrangements for NICE assuming responsibility for the Quality and Outcomes Framework (QOF) for general practice in the UK are also becoming clearer. 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 evidence continues to evolve. It can be argued that you need to foster a variety of different opinions to allow robust debate and that NICE has 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.
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Quality and Outcomes Framework
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 costeffectiveness. 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 6
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behalf of the DoH 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 British Medical Association (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 DoH 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 been accepted and implemented very rapidly. This is unusual: NICE does not have a reputation for speed. By April 2009 NICE had already set up a Primary Care QOF Indicator Advisor y 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 the National Primar y Care Research and Development Centre at Manchester University, the York Health Economics Consortium and the Royal College of General Practitioners. They will be responsible for ensuring cost-effectiveness, producing guidance on implementation, and careful piloting of 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 for ward to the NICE QOF Advisor y 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 www.prescriber.co.uk
Editorial
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. Criticisms
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 the elaborate piloting proposed strictly necessar y as changes can be made annually, as has occurred previously, if necessar y? 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 in 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 postcode variation in care. Beyond England
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 England1 and the consultation for reviewing QOF was managed by the DoH for England. Our NHSs are now very different and this begs the question: can QOF continue to be an all-UK framework? Reference
1. Darzi A. High quality care for all: NHS next stage review final report. DoH, 2008. Conflict of interest
Dr Duerden is on the editorial board of DTB and sits on a NICE technology appraisal committee. Dr Duerden is medical director for Conwy and Denbighshire Local Health Boards and a GP in North Wales, and honorary senior lecturer, Cardiff University www.prescriber.co.uk
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