Inadequacies in the current Quality and Outcome Framework (QOF) indicators in the GMS Contract mean that GPs are rewarded for reaching diabetes targets that would be classified as very poor glycaemic control according to other major guidelines.
The current contract rewards GPs when up to 90% of their diabetes patients have an HbA1c level of ≤10% and up to 50% ≤7.5%, while international guidelines recommend 6.5% or below as the optimal target. Over 60% of patients in the UK with type 2 diabetes on monotherapy have an HbA1c above 7%.
In response to this, and other areas of improvement for diabetes care, the All Party Parliamentary Group on Diabetes (APPGD) has submitted a report which includes pressure on QOF decision makers to lower treatment targets.
GPs are currently rewarded for reaching two separate targets – up to 90% of patients ≤10% HbA1c and up to 50% ≤7.5%. The APPGD suggests that the big gap between 10% and 7.5%, and lack of graded scale between these two figures, does not incentivise physicians to continue to monitor and lower HbA1c.
For every 1% drop in HbA1c, the risk of diabetes-related death and myocardial infarction decreases by 21% and 14% respectively, and microvascular complications such as blindness and kidney disease decrease by 37%. Therefore, one of the key policy suggestions is that an interim target between 10% and 7.5% should be introduced, alongside rewards for 1% drops in HbA1c for all patients.
In addition, as the current HbA1c targets mean that GPs are not being incentivised to get most of their patients to 7.5% and below, let alone to 6.5%, as recommended by other guidelines such as NICE, the All Party Parliamentary Group recommends an additional tighter target of 6.5%. This would encourage more aggressive lowering of HbA1c and offer potentially huge long-term health benefits for people with diabetes.
Adrian Sanders MP, Chair of the All Party Parliamentary Group on Diabetes, said: "The group made a number of valuable suggestions as to how diabetes care could be improved through QOF. It is clear that incentivising GPs to improve their management of patients with diagnosed diabetes, and also those who are at risk of having or developing diabetes will offer huge benefits: not only to the patient in terms of reducing their risk of diabetes-related complications, but also to the NHS, where huge cost savings could be made. The NHS spends approximately £25million a day treating diabetes, the majority of which goes towards paying for the associated complications of the disease."
Other key recommendations in the report were improved integration between primary care and specialist services, greater incentives for GPs to educate patients about diabetes and its treatment and that QOF should be extended to cover identification and prevention measures for those at risk of having/developing diabetes.