GP practices are facing confusion over different approaches to asthma diagnosis set out in the QOF and in the new UK joint guidelines.
In the long-awaited update, NICE, British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) guidelines revealed significant changes to current approaches including the tests used to diagnose asthma.
It advised GPs to use a stepwise series of tests including eosinophil count, FeNO, spirometry and bronchial challenge in patients where the condition is suspected on clinical grounds.
Under the recommendations, asthma can be diagnosed if the eosinophil count is above the laboratory reference range or the FeNO level is 50 ppb or more.
Other objective tests can then be done if asthma is not confirmed, the guidelines said, while also recognising that GPs have limited access to diagnostics in the community.
But under QOF, GPs are expected to have a record of quality assured spirometry and one other objective test, such as FeNO or, bronchodilator reversibility or peak flow variability, between three months before or six months after diagnosis
To achieve points GPs are also expected to do two objective tests in new patients joining the practice who have a diagnosis of asthma but no record of tests being done.
Asthma experts said there was unlikely to be a change to QOF mid-year, leaving GPs in conflict between two sets of guidance – and NHS England has confirmed that QOF was being looked at as part of annual contract updates.
Dr Andy Whittamore, a GP and Asthma and Lung UK Clinical Lead, had already warned that funding and clinician education would need to be available for new diagnostic pathways to be put in place.
He said: ‘QOF and GP contracts and funding will need to update to reflect NICE guidance but unlikely to be changed this financial year.
‘Individual clinicians and organisations will need to take a view on the gap between QOF and NICE so that patients still receive good quality care and so that GP surgeries are not disadvantaged by a change in guidelines mid-year.’
Professor Azeem Majeed, professor of primary care and public health at Imperial College London and a GP in South London, said the differences in the guidelines did pose a potential challenge for GPs.
‘There is a discrepancy between the NICE guidelines, which recommend an eosinophil count or FeNO as the first objective test followed by spirometry if confirmation is needed, and the current QOF requirements, which mandate quality-assured spirometry and one other objective test for diagnosis.
‘This misalignment could cause confusion for GPs and patients, especially since QOF indicators are tied to practice funding and performance assessments.’
He added: ‘In practical terms, GPs are likely to prioritise the QOF requirements, as these directly influence their income. In situations where meeting QOF requirements is challenging , for example due to limited access to FeNO testing, GPs can use exception reporting to explain why certain criteria were not met.’
Professor Majeed said the lag between updates to NICE guidance and QOF was a ‘recurring issue’ that reflected the complexity of aligning evidence-based recommendations with performance frameworks.
‘While this gap persists, GPs may feel caught between adhering to the latest clinical guidance and meeting contractual obligations.’
Dr Steve Holmes, a GP in Shepton Mallet and Somerset ICB clinical respiratory lead, said it would be up to the QOF team to consider how to address the lag between the indicators and the new NICE guidance.
‘I would hope that QOF will adjust rapidly and it would be sensible to ask if they can do this or how they hope practices to manage the situation.’
An NHS England spokesperson said: ‘The NHS works closely with the National Institute for Health and Care Excellence to review the Quality and Outcomes Framework indicators as part of the annual GP contract cycle, and to update them where necessary to align with the latest clinical guidance.’
This article was first published by our sister title Pulse
