National Institute for Clinical Excellence

Please read This is the response form for the NICE indicator consultation 2016. The consultation document should be read before making comments on the indicators listed in this document. As stated in the consultation document, this consultation includes indicators for different uses and settings: .IND CCG - clinical commissioning group outcome indicators .IND GP - general practice indicators for quality improvement general practice indicators for quality improvement, for example to support local schemes .IND QOF - general practice indicators suitable for incentivisation (QOF) Please read the checklist for submitting comments at the end of this form. We cannot accept forms that are not filled in correctly.
Organisation name – stakeholder or respondent (if you are responding as an individual rather than a registered stakeholder please leave blank):	[Insert organisation name]
Disclosure Please disclose any past or current, direct or indirect links to, or funding from, the tobacco industry.	None
Name of commentator person completing form:	Dr Gavin Jamie
Type	[office use only]

Topic	Indicator ID and draft wording	Questions	ID	Comments Insert each comment in a new row. Do not paste other tables into this table because your comments could get lost – type directly into this table.
Antenatal care – seen for booking by 10 weeks	IND CCG1: The proportion of pregnant women accessing antenatal care who are seen for booking by 10 weeks 0 days	Do you think there are any barriers to implementing the care described by this indicator?	1.1	Late presentation may affect delivery of this indicator. This may be due to culture or the movement between areas. Patients may have moved later on.
		Do you think there are potential unintended consequences to implementing / using this indicator?	1.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	1.3
		Do you have any general comments on this indicator?	1.4
Identifying undiagnosed atrial fibrillation (people with comorbidities)	IND GP1: Of those patients registered at the practice aged 65 years and over who have been diagnosed with one or more of the following conditions hypertension, diabetes, CKD, PAD, stroke or COPD and who have had at least one consultation in the preceding 12 months: the proportion that have had a manual pulse palpation on at least one occasion.	Do you think there are any barriers to implementing the care described by this indicator?	2.1	This appears to be a screening programme of the sort rejected by the NSC as not effective. http://legacy.screening.nhs.uk/atrialfibrillation The guidance says that this is supported by NICE guideline but this is not the case. The guideline supports a pulse check with specific symptoms rather than screening of asymptomatic patients. Most of the other references to NICE guidelines are simply incorrect
		Do you think there are potential unintended consequences to implementing / using this indicator?	2.2	Introduction of an inappropriate screening programme
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	2.3
		Do you have any general comments on this indicator?	2.4	Screening in not within the remit of NICE and it should not be proposed by this mechanism.
		Can respondents comment on access to ECG services?	2.5
		People with chronic conditions were identified as an appropriate population for manual pulse palpation. Do stakeholders consider the range of the conditions covered in the indicator suitable?	2.6	No. Pulse should be checked in symptomatic patients.
Identifying undiagnosed atrial fibrillation (people aged 65 years and over)	IND GP2: Of those patients registered with the practice aged 65 years and over who have had at least one consultation in the preceding 12 months: the percentage that has had a manual pulse palpation on at least one occasion.	Do you think there are any barriers to implementing the care described by this indicator?	3.1	No evidence for this screening and it does not have the support of the NICE guidelines that the consultation document claims that it does
		Do you think there are potential unintended consequences to implementing / using this indicator?	3.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	3.3
		Do you have any general comments on this indicator?	3.4
		Can respondents comment on access to ECG services?	3.5
Anticoagulation to prevent stroke	IND QOF1: The percentage of patients with atrial fibrillation and a CHA2DS2-VASc of ≥2 at any time who are not currently treated with anticoagulant therapy who have had a review of the risks and benefits of anticoagulation in the preceding 12 months	Do you think there are any barriers to implementing the care described by this indicator?	4.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	4.2	This could be seen as a “nagging” indicator with patients badgered about their decision annually.
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	4.3
		Do you have any general comments on this indicator?	4.4
		To what extent would this already happen as routine practice during consultations with this population?	4.5	This is largely covered by the exception reporting in the current indicator which already need to be reviewed annually
		Does this indicator expand on the indicator currently in the 2015/16 QOF?	4.6
Review of anticoagulation	IND QOF2: The proportion of people with atrial fibrillation who are prescribed anticoagulation who have a review of the need for and quality of anticoagulation in the preceding 12 months	Do you think there are any barriers to implementing the care described by this indicator?	5.1	No
		Do you think there are potential unintended consequences to implementing / using this indicator?	5.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	5.3
		Do you have any general comments on this indicator?	5.4	Annual review of medications in general is considered good practice although this has been removed from QOF
Stroke rates in people with atrial fibrillation	IND CCG2: Stroke rates in people with atrial fibrillation	Do you think there are any barriers to implementing the care that would impact on this indicator	6.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	6.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	6.3	There are many risk factors for stroke and atrial fibrillation is only one, although a significant one. Smoking rates, deprivation, diabetes, ethnicity etc will all play a part so comparisons between CCGs are likely to be difficult.
		Do you have any general comments on this indicator?	6.4
		If the data are available should this indicator being expanded to include: .Infarction stroke rates in people with atrial fibrillation .Intracerebral haemorrhage stroke rates in people with atrial fibrillation .TIA rates in people with atrial fibrillation	6.5
Chronic kidney disease - register	IND QOF3: The contractor establishes and maintains a register of patients aged 18 or over with CKD	Do you think there are any barriers to establishing and maintaining this register indicator?	7.1	A more complicated route to diagnosis is likely to reduce the numbers of patients on the register. In particular if an ACR is required and this is not returned then patients will not appear on the register. It is also not clear if all current diagnoses will need to be revisted and recoded.
		Do you think there are potential unintended consequences to implementing / using this indicator?	7.2	The number of patients on the CKD register are likely to fall, particularly in the first year, due to the increased complexity of the diagnostic process
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	7.3
		Do you have any general comments on this indicator?	7.4	There is already a code for CKD2 with proteinuria and it might be simplest to add this to the current indicator. The consultation document is not clear if this would be an option rather than a completely new classification system.
		Would expansion of the CKD QOF register to include people with early stages of CKD have clinical value?	7.5
Diabetes HbA1c targets	IND QOF4: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 53 mmol/mol or less in the preceding 12 months. IND QOF5: The percentage of patients with diabetes in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months.	Do you think there are any barriers to implementing the care described by these indicators?	8.1	These indicators appear muddled
		Do you think there are potential unintended consequences to implementing / using these indicators?	8.2	The consultation document quotes the guidelines for Type two diabetes as aiming for less than 58mmol/mol. The threshold in this indicator is for Type one diabetes. However this distinction has not been made. There is potential harm to patients with type two diabetes of over intensive treatment.
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	8.3
		Do you have any general comments on these indicators?	8.4	I would suggest that QOF4 is amended to refer only to patients with type one diabetes.
Type 1 diabetes - statin therapy	IND QOF6: Of the patients with type 1 diabetes who meet the following criteria: aged over 40 years and who have either had diabetes for more than 10 years, or who have established nephropathy or other CVD risk factors; the percentage currently treated with a statin.	Do you think there are any barriers to implementing the care described by this indicator?	9.1	I am not aware of any statins that have a license in children. If a patient is diagnosed at age three or four they could hit the ten year mark aged 13 or 14. I would suggest limiting this to patients over 18 years of age.
		Do you think there are potential unintended consequences to implementing / using this indicator?	9.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	9.3
		Do you have any general comments on this indicator?	9.4
Diabetes in pregnancy	IND CCG3: The proportion of pregnant women with pre-existing diabetes who have a joint diabetes and antenatal care team review within 1 week of referral.	Do you think there are any barriers to implementing the care described by this indicator?	10.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	10.2	This is obviously dependent on the attendance of the mother to be. Perhaps it would be better to say that an appointment is offered in the first week after referral.
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	10.3
		Do you have any general comments on this indicator?	10.4
Diabetes in pregnancy	IND CCG4: The proportion of pregnant women diagnosed with gestational diabetes that have a joint diabetes and antenatal care team review within 1 week of diagnosis.	Do you think there are any barriers to implementing the care described by this indicator?	11.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	11.2	As CCG3
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	11.3
		Do you have any general comments on this indicator?	11.4
Annual diabetes test following gestational diabetes	IND GP3: The proportion of women with a history of gestational diabetes who have had an HbA1c recorded in the preceding 12 months.	Do you think there are any barriers to implementing the care described by this indicator?	12.1	No
		Do you think there are potential unintended consequences to implementing / using this indicator?	12.2	No
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	12.3
		Do you have any general comments on this indicator?	12.4
Complications of diabetes	IND CCG5: Admission rates due to complications associated with diabetes	Do you think there are any barriers to implementing the care that would impact on this indicator?	13.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	13.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.3	13.3
		Do you have any general comments on this indicator?	13.4	This indicator will be very dependent on good information and could be skewed very easily.
Diabetes in children and young people	IND CCG6: Proportion of children and young people who receive the following individual care processes: .Glycated Haemoglobin A1c (HbA1c) monitoring .Body Mass Index (BMI) .Blood pressure .Urinary Albumin .Cholesterol .Eye screening .Foot examination .Smoking .Screening for thyroid and coeliac disease .Psychological assessment	Do you think there are any barriers to implementing the care described by this indicator?	14.1	No
		Do you think there are potential unintended consequences to implementing / using this indicator?	14.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	14.3
		Do you have any general comments on this indicator?	14.4
		If the data are available should this indicator be broken down into age bands of perhaps 5 years – ie, 0 – 5 years, 5 – 10 years, and 10 – 15 years etc.	14.5
Diabetic eye screening	IND CCG7: The percentage of people with diabetes aged 18 years and older who have a record of retinal screening in the past 12 months	Do you think there are any barriers to implementing the care described by this indicator?	15.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	15.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	15.3
		Do you have any general comments on this indicator?	15.4
Annual health assessment in people with learning disabilities	IND GP4: The percentage of patients with a learning disability who have received a health assessment in the preceding 12 months.	Do you think there are any barriers to implementing the care described by this indicator?	16.1	This is currently the subject of a Direct Enhanced Service
		Do you think there are potential unintended consequences to implementing / using this indicator?	16.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	16.3
		Do you have any general comments on this indicator?	16.4	There should be DES statistics available. Does this indicator add anything to the currently available statistics?
Non-elective admissions for people with learning disabilities and autism	IND CCG8: Rates of non-elective admissions for people with learning disabilities and or autism to mental health and general hospital settings	Do you think there are any barriers to implementing the care described by this indicator?	17.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	17.2
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	17.3
		Do you have any general comments on this indicator?	17.4
Recording of BMI	IND QOF7: The percentage of patients aged 18 or over who have had a record of a BMI being calculated in the preceding 5 years.	Do you think there are any barriers to implementing the care described by this indicator?	18.1	I am not sure of the point of this.
		Do you think there are potential unintended consequences to implementing / using this indicator?	18.2	There is currently an indicator in the QOF which effectively offers a payment for each patient who has a BMI recorded of greater than 30 in the QOF year. There is therefore an incentive to record BMI in the obese. This new proposal would extend the incentive to patient with a BMI of less than 30 – over a longer time scale. It neglect the fact that the BMI is not the only assessment of weight that is going on. The clinician in front of the patient will be able to see whether they are overweight by eye. Clinician tend to be quite skilled at this. If this indicator is brought in then it may be that, despite the clinician and the patient both being confident that the patient is of normal BMI they have to be measured anyway “for the computer”. This is the most intrusive sort of indicator that takes time and explanation for no benefit at all.
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	18.3
		Do you have any general comments on this indicator?	18.4
Weight management advice	IND QOF8: The percentage of patients aged 18 years and above with a BMI ≥25 in the preceding 12 months who have been given appropriate weight management advice within 90 days of their BMI being recorded.	Do you think there are any barriers to implementing the care described by this indicator?	19.1
		Do you think there are potential unintended consequences to implementing / using this indicator?	19.2	Essentially this indicator says that no BMI should be measured without the chance of weight management advice. Woe betide anyone who costs the practice points by measuring a BMI without being able to give advice (letting the patient leave the building means that they may not return within the timescale and so cost the practice points) It is likely that fewer BMIs will be measured.
		Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group.	19.3
		Do you have any general comments on this indicator?	19.4
General feedback	N/A	Do you have any general comments?	20.1

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Comments

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