Incentive schemes behind inhaler and edoxaban switching targets should be scrapped, say MPs

MPs have recommended “abolishing” two incentive schemes for general practice, saying they have become “tools of micromanagement”.

In a report, ‘The future of general practice‘, published by the House of Commons Health and Social Care Committee on 20 October 2022, MPs recommended ending the Impact and Investment Fund (IIF) and Quality and Outcomes Framework (QOF) as “they risk turning patients into numbers”.

Incentives laid out in the IIF have faced criticism from pharmacists. In February 2022, pharmacists warned that switching patients from metered-dose inhalers to “low-carbon” dry powder inhalers and soft mist inhalers — an IIF incentive to reduce avoidable emissions — without proper consultation, could lead to worsening disease control.

Then, in August 2022, primary care pharmacists revealed that patients were being switched to edoxaban, in line with an IIF incentive, without being informed or when it was not clinically appropriate.

“Accountability and quality improvement are both extremely important in the NHS but it is clear that the current system of targets and incentives in general practice is overly bureaucratic, is not having the desired effect on outcomes, and will not enable GPs to change the way care is delivered,” the report said.

It added that the funding from the incentive schemes should be reinvested in general practice and “weighted to account for patient demographics including deprivation, to incentivise continuity of care”.

A spokesperson for the Primary Care Pharmacy Association (PCPA), said: “It is clear that the aims of these frameworks are designed to improve care and do provide a framework to ensure long-term conditions are managed in line with current guidance.

“However, we would suggest that these systems could be streamlined, possibly into one system.

“Frameworks have to be designed to provide assurance of quality and funding well spent — no two practices or [primary care networks] are exactly the same, and naturally incentivising optimal patient outcomes should be the aim of any system.”

The spokesperson added that the PCPA would like to see incentives that ensure the changing model of working in community pharmacy is incorporated, including incentives relating to “hypertension case-finding and the CPCS [Community Pharmacist Consultation Service]”.

The select committee’s report also noted that the recruitment of additional healthcare professionals — including pharmacists — into primary care networks (PCNs) is “not yet making a meaningful impact on the future sustainability of general practice”.

“Instead, we heard that patients can become confused over who they are signposted to and why,” the report said.

PCNs began recruiting pharmacists following the announcement of the Additional Roles Reimbursement Scheme in January 2019, which funds their recruitment into general practice.

However, Janet Morrison, the lead negotiator of the community pharmacy contract has called on the government to stop the recruitment of pharmacists into PCNs, amid workforce concerns.

Thorrun Govind, chair of the Royal Pharmaceutical Society’s English Pharmacy Board, said everyone working in the pharmacy profession also identified with the challenges facing colleagues in general practice, namely managing a complex workload, a workforce under strain and growing demand on the NHS.

“Pharmacists and pharmacy technicians play a vital role in primary care, including in general practice, community pharmacy and across PCNs,” she said.

Govind added that, with continued pressure across the health service, the government must ensure they use the expertise of the whole of the workforce, including maximising referrals into the Community Pharmacist Consultation Service, funding a ‘Pharmacy First’ approach to minor ailments in England, and using the growing numbers of pharmacist independent prescribers.