Covering: contractual position, patient safety and the case for a commissioned service                                                                                                                                                                                                                                                                                                                                                                                                                

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9 June, 2026

NEL LMCs position statement on DOACs monitoring

Dear <<First name>>,

Purpose of this document

This paper sets out the position of North East London LMCs regarding the ongoing monitoring of patients prescribed direct oral anticoagulants (DOACs).

The paper is intended to inform discussions between NEL ICB, NHS England London Region, Londonwide LMCs, providers and system partners. 

It addresses:

1. the clinical nature of DOAC monitoring;
2. the contractual position in general practice;
3. why QOF and local quality schemes do not create a contractual obligation to provide unfunded monitoring;
4. examples of other areas where DOAC monitoring is commissioned locally; and
5. the options available to NEL ICB if it wishes general practice to deliver this work safely and consistently.

Executive summary

DOAC monitoring is clinically necessary, safety-critical, and increasingly high-volume work. It includes more than the issuing of a repeat prescription. It requires identification of the eligible cohort, maintenance of a register, recall, blood testing, calculation of creatinine clearance using an appropriate method, review of weight, renal function and bleeding risk, assessment of adherence and adverse effects, dose adjustment where required, management of abnormal results, patient counselling, coding, and clear arrangements for escalation.

Across North East London, the LMCs understand that approximately 33,000 patients are prescribed DOACs. Each of these patients requires regular monitoring, with many requiring more than annual monitoring because of age, frailty, renal impairment, comorbidity or interacting medication.

The LMCs' position is that DOAC monitoring is not funded as part of the core GMS/PMS/APMS contract. It requires a defined, structured, safety-critical medicines monitoring service. Where commissioners want general practice to deliver this service at scale, it should be commissioned and resourced through an appropriate local enhanced service or locally commissioned service.

QOF does not resolve this issue. QOF is a voluntary incentive scheme and does not convert non-core or unfunded work into a contractual requirement. QOF indicators relating to atrial fibrillation and anticoagulation incentivise aspects of prescribing and recording; they do not constitute a comprehensive funded service specification for ongoing DOAC monitoring.

Similarly, a local quality framework or prescribing incentive cannot be used to imply that practices are already funded to provide a comprehensive anticoagulation monitoring service. If such a framework generates additional activity, clinical responsibility, patient recall, monitoring, coding, reporting and escalation, then the activity must be properly specified and funded.

The ICB therefore has a clear choice. It can either:

1. commission general practice to provide DOAC monitoring through a properly funded LCS; or
2. commission another provider, such as community anticoagulation, haematology, pharmacy or another suitable provider, to provide the service.

However, where there is no commissioned community service, ongoing monitoring and prescribing responsibility cannot safely be assumed to sit with practices by default. General practice has never delivered anticoagulation services as part of its core contract; the default position is therefore for the service to be delivered by secondary care haematology services.

The clinical reality of DOAC monitoring

DOACs do not require INR monitoring in the way warfarin does. However, they are not “no monitoring” medicines.

Safe DOAC prescribing requires:

• baseline assessment before initiation;
• assessment of renal function using creatinine clearance, not simply eGFR;
• review after initiation and/or dose change;
• ongoing monitoring once stable;
• more frequent review for patients with renal impairment, frailty, advanced age, intercurrent illness, hepatic impairment, interacting medicines, bleeding risk or other clinical concerns;
• dose review according to indication, renal function, age, weight and drug-specific criteria;
• review of adherence, bleeding, anaemia, thromboembolic symptoms, adverse effects and drug interactions;
• patient counselling and safety-netting;
• action on abnormal results, including dose change, treatment interruption, referral or specialist advice where needed.

This is structured medicines monitoring and clinical review. It is not simply an administrative repeat-prescribing task.

Contractual position

The core GP contract requires practices to provide essential primary medical services to registered patients. It does not contain a specific anticoagulation monitoring service specification and does not set out the infrastructure, call/recall, safety standards, review intervals, coding, reporting, escalation, or payment arrangements required for DOAC monitoring.

A practice may, in the course of ordinary clinical care, identify risks, respond to abnormal results, prescribe safely, and act in a patient’s best interests. That does not mean that the commissioner can require the practice to operate a population-level anticoagulation monitoring service without specification or funding.

The LMCs' position is therefore:

• safe prescribing remains a professional obligation for any clinician issuing a prescription;
• practices should not knowingly issue unsafe repeat prescriptions;
• however, the establishment and operation of a systematic DOAC monitoring service is not automatically funded under core GMS/PMS/APMS;
• where the system requires practices to undertake proactive monitoring, recall, review, coding, reporting and escalation for a defined DOAC cohort, this should be commissioned as an enhanced or locally commissioned service;
• alternatively, both monitoring and prescribing may take place, by default, in a secondary care haematology service.

QOF does not fund or mandate DOAC monitoring

The ICB has suggested that existing mechanisms such as QOF and local quality frameworks provide sufficient support for this work. The LMCs do not agree.

QOF is a voluntary incentive scheme. It rewards achievement against defined indicators. It does not create a general contractual obligation to deliver all associated clinical work, nor does it provide a comprehensive service specification for medicines monitoring. Practices may choose to decline to undertake the work associated with QOF and forfeit the incentive payments.

The current AF anticoagulation indicator concerns whether eligible patients with atrial fibrillation are prescribed a DOAC, or where unsuitable or declined, a vitamin K antagonist. That is not the same as funding an anticoagulation monitoring service.

A DOAC monitoring service requires, at minimum:

• a maintained DOAC register;
• identification of monitoring intervals;
• patient recall;
• blood tests;
• weight review;
• Cockcroft-Gault creatinine clearance calculation;
• review of dose appropriateness;
• review of bleeding risk and adverse effects;
• action on abnormal results;
• coding and documentation;
• escalation routes;
• patient information and safety-netting;
• governance and audit.

QOF does not specify or fund that service.

Local quality frameworks cannot redefine core contract

The same principle applies to any NEL local quality or proactive care framework. Such schemes may incentivise quality improvement or prescribing optimisation. They cannot, by implication, redefine the core GP contract or require practices to accept unfunded clinical responsibility for a complex medicines monitoring pathway.

If a NEL quality scheme asks practices to undertake DOAC searches, reviews, dose optimisation, coding, recalls or monitoring, then it should be treated as commissioned activity and funded accordingly.

The LMCs would be particularly concerned by any attempt to use a local quality indicator to suggest that practices have accepted responsibility for the entire DOAC monitoring pathway. Agreement to participate in a quality improvement scheme is not the same as agreement to provide an unfunded anticoagulation monitoring service.

Patient safety risks if the service is not commissioned

The current position creates avoidable clinical risk.

Without a commissioned service, monitoring becomes dependent on variable local capacity, goodwill, prescribing workflows, medicines management searches and opportunistic review. That is not a robust system for a high-risk medication cohort.

Risks include:

• patients remaining on inappropriate doses after renal function changes;
• eGFR being used instead of creatinine clearance;
• frail or older patients not being monitored frequently enough;
• weight changes not being captured;
• interacting medicines not being reviewed;
• abnormal haemoglobin, liver function or renal function not being acted on consistently;
• unclear responsibility between GP, hospital specialist, anticoagulation service and pharmacy;
• unsafe assumptions that “the GP is monitoring” when no funded pathway exists;
• inequity between boroughs and practices; and
• increased medicolegal risk for practices and individual prescribers.

The LMCs' concern is not theoretical. DOACs are high-risk medicines. The system must be clear about who is responsible for monitoring, how patients are recalled, how results are reviewed, and how abnormal findings are escalated.

Examples from other areas

The BMA recognises the monitoring of DOACs as a service that requires commissioning from practices.

Until recently, NEL ICB commissioned a DOAC monitoring service from general practice in Tower Hamlets. This service was withdrawn at the end of March 2026.

Other ICB systems have recognised that DOAC monitoring is legitimate locally commissioned activity. Examples include the following:

North Central London has a Direct Oral Anticoagulant Locally Commissioned Service. Its stated aims include improving DOAC initiation and monitoring in primary care, maintaining a register of patients on DOAC therapy, providing patient information, ensuring safe initiation and maintenance, identifying vulnerable patients, and providing at least annual monitoring review.

North West London has included DOAC review and optimisation within its single offer enhanced service arrangements, including review of patients prescribed DOACs for atrial fibrillation, confirmation that dose is optimised in line with recent renal function, and specified coding requirements.

Both Surrey and Sussex ICBs have commissioned a Direct Oral Anticoagulant LCS with payments for DOAC monitoring.

Kent and Medway have also moved towards a commissioned response following challenge from general practice and the LMC, including discussion of a DOAC monitoring service and interim payment in lieu of the shared care and DOAC monitoring service.

These examples demonstrate that NEL’s current position is not aligned with other ICBs. Other systems have accepted that DOAC monitoring requires commissioning, specification and resource.

Proposed minimum service specification

If NEL ICB wishes general practice to provide DOAC monitoring, the LMCs recommend that the ICB commissions a DOAC Monitoring LCS with the following minimum components.

Eligible patients

All registered patients prescribed a DOAC by the practice, including apixaban, rivaroxaban, edoxaban and dabigatran, for any indication where ongoing prescribing and monitoring has been accepted by the practice.

The specification should distinguish between:

• patients initiated in general practice;
• patients initiated in secondary care and transferred to general practice;
• patients under active specialist follow-up;
• patients with complex indications or unstable clinical status;
• patients for whom monitoring should remain with a specialist anticoagulation service.

Core activity

The service should fund:

• maintenance of a DOAC register;
• identification of patients due monitoring;
• call and recall;
• blood tests, including FBC, U&Es/creatinine and LFTs;
• weight recording where required for dose assessment;
• Cockcroft-Gault creatinine clearance calculation;
• dose review according to indication, renal function, age, weight and drug-specific criteria;
• adherence review;
• bleeding and anaemia review;
• review of thromboembolic symptoms;
• review of adverse effects and drug interactions;
• patient counselling and written information;
• coding;
• repeat prescribing governance;
• referral or specialist advice where required; and
• annual audit or reporting proportionate to the service.

Review frequency

The service should fund annual review as a minimum, with more frequent monitoring for higher-risk patients, including patients who are older, frail, have renal impairment, have hepatic impairment, have interacting medicines, or have intercurrent illness affecting renal or hepatic function.

The service must recognise that some patients will need two, three or more reviews per year, not simply one annual review.

Exclusions and escalation

The service should specify when responsibility remains with or returns to specialist care, including:

• unstable renal function;
• severe renal impairment;
• significant hepatic impairment;
• suspected bleeding or unexplained anaemia;
• recurrent thrombosis or embolic events;
• complex indications;
• uncertainty about dose or drug choice;
• patients requiring specialist anticoagulation advice;
• patients in whom DOAC therapy may be contraindicated.

Payment model

The payment model should reflect both fixed infrastructure and variable workload. Options include:

• a fixed annual practice payment for register maintenance, search work, governance and reporting; plus
• a per-patient payment for annual DOAC review; plus
• an additional payment for higher-risk patients requiring more frequent monitoring; plus
• separate payment where initiation or switching is requested.

A simple single per-patient payment risks underfunding older, frailer, renal-impaired and complex patients. Any payment should reflect actual workload and should not assume that all DOAC patients require the same level of review.

Data and reporting

Reporting should be proportionate and based on data practices can reasonably record and extract. It should not become a separate administrative burden greater than the clinical work itself.

Suggested indicators include:

• number of patients on DOAC register;
• percentage with creatinine clearance recorded within appropriate interval;
• percentage with DOAC dose reviewed;
• percentage with FBC/LFT/U&E monitoring completed within appropriate interval;
• number referred/escalated for specialist advice;
• exception reporting for non-attendance or patient refusal.

Recommended system position

The LMCs recommend that London Region support the following position.

1. DOAC monitoring is clinically necessary and safety-critical.
2. It is not equivalent to ordinary repeat prescribing.
3. It is not comprehensively funded or specified through QOF.
4. Neither QOF nor local quality indicators can redefine the core GP contract.
5. Where the ICB wants practices to deliver this work systematically, it should commission a properly specified LCS.
6. In the absence of such a service, the ICB must identify the provider responsible for ongoing monitoring and make that pathway clear to practices, patients, community pharmacies and secondary care.
7. The ICB should not rely on unfunded practice goodwill to mitigate a known medicines safety risk.

Practical asks of NEL ICB

NEL LMCs therefore ask NEL ICB to:

1. confirm in writing whether it accepts that DOAC monitoring requires a defined pathway;
2. confirm whether it wishes general practice to provide that pathway;
3. if yes, co-develop a DOAC Monitoring LCS with Londonwide LMCs;
4. if no, identify the commissioned alternative provider responsible for monitoring;
5. issue clear guidance to secondary care, community pharmacy and practices about where responsibility sits;
6. confirm that QOF and PCQOF participation will not be treated as acceptance of unfunded DOAC monitoring responsibility;
7. agree a safe transition period while arrangements are put in place; and
8. ensure that any service is funded at a level reflecting the real workload and risk.

Suggested wording for practices

Until the position is resolved, practices should continue to act in patients’ best interests and should not knowingly issue unsafe prescriptions. However, practices are not required to absorb an unfunded anticoagulation monitoring service by default.

Where a patient requires structured DOAC monitoring and no commissioned general practice service exists, practices may reasonably ask the ICB to confirm the appropriate commissioned monitoring pathway. Where specialist advice or review is clinically required, patients should be referred or signposted according to the available local pathway.

The LMCs will continue to engage with NEL ICB and London Region to seek a safe, funded and contractually clear solution.

Conclusion

DOAC monitoring is important work. It prevents avoidable harm and supports safe anticoagulation. But important work is not automatically core work, and patient safety cannot depend on unfunded, implied transfer of responsibility to general practice.

NEL ICB should either commission general practice to deliver DOAC monitoring properly, or commission another provider to do so. What is not acceptable is an ambiguous position in which practices are expected to carry the workload and risk without a service specification, without funding, and without clear system accountability.

Best wishes,

North East London LMCs

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