The 2013/14 General Medical Services contract: What we need to know for diabetes care

For the first time since the Quality and Outcomes Framework (QOF) was introduced on 1 April 2004, the UK government has effectively forced the General Medical Services (GMS) contract on practices, with the General Practice Committee (GPC) of the British Medical Association (BMA) in England refusing to agree this round of contract changes, describing it as an “imposed contract”. The GPCs in Northern Ireland, Scotland and Wales have agreed to local versions of the contract, which take local workforce considerations into account. Again, for the first time since its inception, the GMS contract would appear to have significant variations between the four nations of the NHS, although it seems that the QOF clinical indicators (NHS Commissioning Board et al, 2013) are broadly the same throughout the UK.

In the Autumn of 2012, the UK government set out its proposals to implement the NICE-suggested amendments to the GMS contract from April 2013, making clear its commitment to pursue changes to the GMS and to impose these should it not be possible to reach a satisfactory negotiated agreement. The GPC of the BMA sought to negotiate with the government, stating that, while many of the proposed contract changes had been suggested by NICE, many of these changes, especially the raised thresholds, would significant impact on the workload of primary care and had the potential to negatively impact on patient care. The GPC surveyed GP members, who were almost universally opposed to the changes (BMA GPC, 2013). In a letter to the government, Laurence Buckman (GPC Chair) stated that “we believe that the proposals simply ask too much of an already stretched service.” It would seem inevitable that this has the potential to impact on the care of people with diabetes.

Below-inflation funding increase for practices
The Department of Health (DH) recently announced that it would increase GMS funding by 1.32% in 2013/14 in England (1.5% in Northern Ireland), despite advice from the independent Doctors and Dentists Review Body that general practice should be awarded a 2.29% rise (BMA, 2013a). In keeping with this large overhaul of QOF, the majority of organisational indicators, worth around £20 000 per practice, will be removed (DH, 2013). Practices in England will still be expected to carry out the work covered by these “retired” indicators as part of clinical governance, but will now be expected to fulfil four new enhanced services to earn back the equivalent sum that they brought to the practice. The other three nations have adopted variations of this.

These enhanced services will cover:

• A more proactive approach to people who may have dementia, including family support.
• Improving care management for seriously ill patients or people at risk of unplanned hospital admission, such as frail older individuals.
• Ensuring individuals can book appointments and order repeat prescriptions online.
• Arranging remote monitoring for people with long-term conditions.

In the next section, changes to diabetes-specific clinical indicators are considered.

Changes to diabetes-specific clinical indicators
Modified indicator
One diabetes indicator has been modified:

1. DM001 – A register of people with diabetes must be established and maintained for all patients aged 17 years or over with the condition. As before, where a diagnosis has been confirmed, this must be clarified between type 1 and type 2. Practices wishing to interrogate their clinic systems to differentiate between type 1 and type 2 diabetes can download a useful tool at: http://www.clininf.eu/cod (accessed 30.04.13).

New indicators
Four new diabetes indicators have been introduced into QOF (excerpts from the rationales given are provided in Table 1):

1. DM013 – The percentage of patients with diabetes who have a record of a dietary review by a suitably competent professional in the preceding 15 months.
2. DM014 – The percentage of patients newly diagnosed with diabetes in the preceding period between 1 April and 31 March who have a record of being referred to a structured education programme within 9 months of entry on to the diabetes register. 
3. DM015 – The percentage of male patients with diabetes with a record of being asked about erectile dysfunction in the preceding 12 months. 
4. DM016 – The percentage of male patients with diabetes with a record of erectile dysfunction who have a record of advice and assessment of contributory factors and treatment options in the preceding 12 months. 

The GPC argued that many practices would not have local access to structured education programmes. In a slight concession, the DH acknowledged the fact that it may not be possible to identify a suitable referral service locally that all patients could attend and has thus allowed new exception codes to identify where a secondary service is not available. 

Enquiries about impotence are important and should be conducted in a sensitive manner. It is difficult to imagine, however, that there will be sufficient time during a short diabetes review for a full therapeutic discussion.

Retired diabetes indicators
Three diabetes indicators have been retired:

1. The percentage of patients with diabetes with BMI recorded in the preceding 15 months.
2. The percentage of patients with diabetes with a record of neuropathy testing in the preceding 15 months.
3. The percentage of patients with diabetes who have a record of estimated glomerular filtration rate or serum creatinine testing in the preceding 15 months.

With regard to point 2, it should be noted that maintained as before is DM012: The percentage of patients with diabetes on the register with a record of a foot examination and risk classification – [1] low risk (normal sensation, palpable pulses); [2] increased risk (neuropathy or absent pulses); [3] high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer); or [4] ulcerated foot within the preceding 12 months.

The points released by retiring these indicators have been used in other ways.

Rise in thresholds and reduced periods for diabetes review
Most QOF indicators reward practices according to the proportion of eligible patients who benefit from the indicator and have upper and lower payment thresholds based on percentages of patients. Practices do not earn points until they exceed the lower threshold. All the threshold ranges for the new diabetes indicators are set at 40–90%. The DH judged that national average achievement is currently above the upper thresholds for all indicators, suggesting that there was no incentive for practices to improve the range of their diabetes care. The DH proposes, therefore, that the evidence of what is practically achievable should be based on the latest data available on achievement of the 75th centile of practices. The DH has also removed overlapping time-periods from most indicators’ measuring processes or intermediate targets, by reducing these periods from 15 to 12 months or from 27 to 24 months. Practices should be aware that there are variations among the four nations in how these thresholds and time periods have been agreed and are advised to seek guidance from their local primary care organisations.

Thoughts on other relevant changes
Among various changes to other indicators relevant to diabetes, including those in the area of cardiovascular disease, two new hypertension indicators have been introduced (for full details, refer to NHS Commissioning Board et al, 2013):

1. HYP004 – The percentage of patients with hypertension aged 16–74 years in whom there is an annual assessment of physical activity, using the General Practice Physical Activity Questionnaire (GPPAQ), in the preceding 12 months.
2. HYP005 – The percentage of patients with hypertension aged 16–74 years scoring “less than active” on GPPAQ in the preceding 12 months who also have a record of a brief intervention in the preceding 12 months.

The GPC argued that there was not an obvious resource to which such individuals with hypertension could be referred (BMA, 2013b); thus, the DH has phased in, over 2 years, the thresholds for the two new indicators that reward advice for increasing physical activity for individuals with hypertension. 

Conclusion
There is much for practices actively managing people with diabetes to consider as this new QOF year begins. Practices will want to recognise that this latest round of changes to QOF is the biggest upheaval in its 9 years. There are new diabetes, hypertension and cardiovascular risk indicators. Thresholds for payment and overall timings are reduced from 15 to 12 months. In spite of a representative survey of BMA members pointing out many flaws, and very reasoned arguments by the GPC of possible patient harm, the DH is pressing ahead with changes that will have a considerable impact on practice workload, as well as significantly impacting on the lives of people with diabetes.