On the 6 February, NHS England issued an update to the GP contract agreement 2020/21 to 2023–23/24. The update includes important improvements to the asthma and COPD domains.

Throughout 2019 PCRS worked with colleagues including NICE, PHE, RCGP and the National Clinical director to ensure that QOF continues to improve to meet the needs of people with respiratory disease and tobacco dependency. We are pleased to see some positive progress now as a number of the NICE agreed respiratory indicators championed by PCRS during discussions in 2019 have made it into the 2020/21 contract. We are expecting more detail by the end of March about what exactly will need to be recorded and performed in order to attract the necessary QOF points and will report back then. In the meantime, here are the headlines and what they mean for primary and community-based care.

Asthma domain

• Practices will be required to establish and maintain a register of patients aged 6 years and over with a diagnosis of asthma, in line with NICE guidance;

Practices have always had to keep an asthma register since QOF started in 2004. This metric deviates slightly from the NICE 2019 approved metric which suggested a start age of 5. We look forward to seeing the detail about what results in inclusion.

• Practices will be expected to use a minimum of two diagnostic tests to confirm an asthma diagnosis. These tests should be performed up to 3 months before any date of diagnosis and up to 6 months after this date;

Looking for an objective measure to support the clinical diagnosis of asthma has been a part of QOF for many years. Most practices will have used PEFR diaries and looked at response to treatment with inhaled corticosteroids to show that the symptoms are variable over time and reversible.  PCRS continues to support this pragmatic approach to asthma diagnosis in people presenting with high probability of asthma. Our latest update to the PCRS consensus approach to asthma describes this.

This new indicator follows the NICE asthma diagnosis pathway which aspires to see every new asthma diagnosis having two objective tests to support the clinical suspicion. We have already reported that this will be challenging for practices and will ultimately depend on new ways of working. We have not seen the detail about whether PEFR diaries will be accepted as one of the measures. FeNO and spirometry are the tests expected to be performed by NICE in primary care, albeit with the high false positive rate associated with FeNO testing and the limitations of a single point-in-time spirometry evaluation. We expect to see these increasingly being performed at PCN level due to costs and expertise requirements.

• The content of the asthma review has been amended to incorporate aspects of care positively associated with better patient outcomes and self- management;

We will be looking out here for the detail to see whether new measures to achieve points for an annual asthma review will include i) over-reliance on SABA and ii) exacerbation count. This was included in the NICE August 2019 recommendation “… includes an assessment of asthma control using a validated asthma control questionnaire (including assessment of short acting beta agonist use), a recording of the number of exacerbations”

• Practices will be required to record smoking exposure in children and young people under the age of 19 years.

We welcome that heightened awareness of the link between smoking tobacco and asthma outcomes is being maintained through inclusion in QOF. We believe this is relevant to people of all ages and this is captured elsewhere in QOF. PCRS made a strong case for the recording of passive tobacco smoke inhalation risk to be recorded. Again, we look forward to the detail to see how this will be captured and how it will impact on our patient and parent/carer consultations.

COPD domain

• Entry to the COPD register will be determined by the presence of a clinical diagnosis plus a record of post bronchodilator spirometry FEV₁/FVC ratio below 0.7 recorded between 3 months before or 6 months after diagnosis in diagnoses made on or after 1 April 2020;

This is a profound change to COPD QOF that we have been campaigning for many years on. The Primary Care RCP National Asthma and COPD audits (NACAP) in Wales between 2014 and 2017 showed a worrying disparity between the QOF achievement for COPD confirmed by spirometry and the reality of whether the values obtained through spirometry were consistent with a diagnosis of airways obstruction. The good news for practices and PCNs is that the requirement will start this year and doesn’t have to include all historic diagnoses. There may be limitations to the measure as it may not take account of the FEV₁/relaxed VC or capture those patients with radiological emphysema and a normal ratio. We support the review of past patients being reviewed to check their spirometry was accurate and consistent with diagnosis, but better future diagnosis is a real and significant opportunity now.

• The annual review will include a requirement to record the number of exacerbations in order to help guide future management and potentially avoidable emergency admissions.

We know from membership surveys that the vast majority of HCPs are following a GOLD style guideline for managing COPD. This pathway requires the measurement of exacerbations, but we know from the NACAP Wales primary care work that this is rarely recorded because historically FEV₁ measurement (now gone from QOF since 2019/20) became an over-focus in annual reviews. The new measurement of exacerbation count is welcomed and again we can thank the work of the RCP NACAP team in bringing the need for this measurement to the fore. PCRS regularly updates its approach to managing the types of COPD that people present with through our Pragmatic Guide to COPD.

We have previously written about how value can be obtained through the QOF contract. These proposed indicator changes were published for consultation in May 2019. The final list of indicators approved by NICE in August 2019 can be seen here and even if they haven’t made it into the contract, they are still useful as quality improvement tools in local schemes so do have a look.

Noel Baxter, Executive Policy Lead

24 February 2020