Assistant Web Editor
Tricia Bryant

GPIAG PRESS RELEASE (03/04/06)

Although the changes are relatively minor, the GPIAG welcomes those amendments to the Quality and Outcome Framework (QOF) which might be expected to improve the care of people with respiratory disease.ⁱ

A number of diagnostic issues have been clarified. The recognition that one peak flow reading provides no information about variability and therefore can neither confirm, nor refute, the diagnosis of asthma, reflects one of the recommendations submitted by the General Practice Airways Group (GPIAG) to the QOF review process. The updated guidance clarifies the importance of seeking objective evidence of variability to support a suggestive history, and offers practical advice on how this may be achieved in primary care. Similarly, we applaud the continuing emphasis on excluding asthma by checking for substantial reversibility when confirming a diagnosis of chronic obstructive pulmonary disease (COPD). The confusion caused by the implication of the first QOF that patients cannot have both asthma and COPD, has now been further clarified with the helpful indication that the overlap will be in the order of 15%.

We remain very concerned that the payment threshold adopted by QOF for a diagnosis of COPD (an FEV1 less than 70% of predicted) is out of line with national and international guidelines, who define COPD as an FEV1 less than 80% predicted.^{ii iii} QOF is encouraging clinicians to 'ignore' a substantial proportion of people with mild COPD. Whilst we agree that these people are less likely to require drug therapy, establishing the diagnosis and using the opportunity to strongly encourage smoking cessation is fundamental to preventing progression of their COPD to moderate and severe disease.^iv The GPIAG would recommend that all patients with a post-bronchodilator FEV1 less than 80% predicted and an FEV1/FVC ratio less than 70% predicted should be entered on the practice COPD register. Such patients should be offered an explanation of their condition with advice to quit smoking and, at appropriate intervals, have their lung function repeated and functional impairment assessed to establish rate of decline and the need for therapeutic intervention.

Two of the new disease areas included in the updated QOF impact on the management of respiratory disease. The GPIAG welcomes the explicit inclusion of patients with respiratory disease in the palliative care indicators. The needs of people with very severe COPD are rarely adequately addressed in practice,^v and we hope that inclusion in QOF will encourage practitioners to offer appropriate services to this severely disabled group of patients. We are disappointed that the substantial incidence of depression in people with COPD has not been formally recognised, despite an incidence similar to that in heart disease and diabetes.^vi

Clarity on the potential functions of an asthma review is welcomed, and reflects several of our recommendations. However, we are disappointed that specific targets have not been set for the provision of Personal Asthma Action Plans. Although patients with more severe asthma have the most to gain, there are important studies which confirm that self-management education improves morbidity in primary care populations.^{vii viii} The injunction merely to 'consider' offering a personalised asthma plan compares unfavourably with the imperatives (e.g.to 'measure peak flow' and 'check inhaler technique') and is likely to discourage self-management education.

The recent ruling of the Implementation Co-ordination Group not to support telephone consultations, conflicts with the policy agendas of improved access and patient choice. Telephone asthma reviews increase the proportion reviewed and are welcomed as convenient option by patients.^{ix x} We are concerned that this will prove to be a perverse ruling that encourages practices to 'exception report' patients unable or unwilling to attend face-to-face reviews, rather than seek to facilitate reviews by offer alternative modes of consultations.

Background information

The GPIAG, in a process which involved consultation with its membership, submitted recommendations to the official review process to add seven new indicators to the Quality and Outcomes Framework of the GMS contract. These may be downloaded from http://www.gpiag.org/news/qof2.php

The General Practice Airways Group (GPIAG) is an independent charity representing primary care health professionals interested in delivering the best standards of respiratory care. It is dedicated to achieving optimal respiratory care for all through:

• Facilitating and leading primary care respiratory research
• Promoting best practice in primary care respiratory health through education, training and other services
• Representing primary care respiratory health needs at policy level' For more information, including details of how to join, please visit www.gpiag.org.

1. British Medical Association and NHS Confederation. Revisions to the GMS contract, 2006/07: Delivering Investment in General Practice. http://www.bma.org.uk/ap.nsf/Content/revisionnGMSFeb20062
2. National Institute for Clinical Excellence. National clinical guideline management of chronic obstructive pulmonary disease in adults primary and secondary care. Thorax 2004; 59 (Suppl. 1): S1-232
3. Global Initiative for Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease; NHLBI/WHO workshop report Updated 2003. Online. Available: www.goldcopd.com
4. Thomas M. COPD management in the community: early detection and proactive care. Prim Care Respir J 2005; 14: 5-7
5. Gore JM, et al. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax 2000; 55: 1000-6
6. Edmonds P. et al A comparison of the palliative care needs of patients dying from chronic respiratory diseases and lung cancer. Palliative Med 2001; 15: 287-95
7. Mougdil H et al. Asthma education and quality of life in the community: a randomised controlled study to evaluate the impact on white European and Indian subcontinent ethnic groups from socioeconomically deprived areas in Birmingham, UK. Thorax 2000; 55: 177-183
8. Thoonen et al. Self-management of asthma in general practice, asthma control and quality of life: a randomised controlled trial. Thorax 2003; 58: 30-36
9. Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D, Sheikh A. Accessibility, acceptability and effectiveness of telephone reviews for asthma in primary care: randomised controlled trial. BMJ 2003; 326: 477-479
10. Pinnock H, Snellgrove C, Madden V, Sheikh A. Telephone or surgery asthma reviews? Preferences of participants in a primary care randomised controlled trial Prim Care Respir J 2005; 14: 42 -46