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Financial incentives for quality in UK primary medical care

Financial incentives for quality in UK primary medical care. Ruth McDonald Nottingham University Business School. National Workshop on Results-Based Financing for Health Jaipur, India January 28, 2010. UK Context. Primary care doctors (GPs) Patients register with practice

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Financial incentives for quality in UK primary medical care

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  1. Financial incentives for quality in UK primary medical care Ruth McDonald Nottingham University Business School National Workshop on Results-Based Financing for Health Jaipur, India January 28, 2010

  2. UK Context • Primary care doctors (GPs) • Patients register with practice • Contract to provide services • Historically vague contract • Capitation • Little information on what GPs did • Wide variation in practice

  3. Background • Profession resisted attempts to measure quality • New contract 1990 – profession rejected, but government imposed • Handful targets, incentives (e.g. cervical cytology, childhood immunisation)

  4. Changing context • High profile scandals • Proliferation of quality measures & growing acceptance • Increasing workload (chronic conditions from secondary care, 24/7 care) • Low morale • Low status & pay (relative to hospital) • Problems with recruitment

  5. NHS ‘modernisation’ • NHS fit for 21st century • Big investment in primary care • Incentives not aligned with policy goals • New contract 2004 to tackle problems

  6. Aims • Improve productivity • Redesign services around patients • Skill mix • High quality care (& culture of governance) • Extend range of services • Recruitment, retention & morale

  7. Reforms • 2004 contract with organisation NOT individual doctor • End to out of hours responsibility • Quality & Outcomes Framework (QOF) • 146 targets • Clinical, organisational , patient experience, additional services

  8. QOF indicators & points • Clinical 76 indicators; 550 points • Organisational 56 indicators; 184 points • Patient experience 4 indicators; 100 points • Additional services (cervical screening, child health surveillance, maternity services, and contraceptive services) 10 indicators; 100 points • 100 holistic care; 30 quality practice

  9. 2004 contract • Primary care trust (PCT) • QOF Voluntary • QOF – up to 30% practice income • Negotiation • Ballot – 79% support (of 70% turnout)

  10. QOF points -CHDExample • register of patients 4 • %patients newly diagnosed angina referred for exercise testing and/or specialist assessment 7 (40-90%) • %patients BP recorded 15 mo. 7 (40-90%) • %patients BP 150/90 or less 17 (40-70%) • %patients cholesterol 5mmol/l or less 17 (40-70%)

  11. Data collection & verification • Computerised disease registers, call & recall systems • Computerised records, templates & prompts during patient consultation • Performance data extracted from electronic health records in practice systems • PCTs visit practices • Look at data across practices • Outliers

  12. ‘Gaming’ • Can ‘exception report’ patients (exclude from target calculations) • Low disease prevalence (case finding) • False recording • PCT checking, outliers • GPs – QOF assessors, ‘peer’ review

  13. Impact vs. plan? • Hard to tell (initially) • High levels of attainment • Big overspend vs. plan - £1.76 billion or 9.4 % • Modest improvements on quality indicators • Reduction in doctors’ hours worked & productivity (fallen by average of 2.5 % per year in 2004 & 2005)

  14. Impact vs. plan? • Reduction in inequalities • Morale improved initially • Skill mix changes – nurses 30% of consultations, increase in number of salaried doctors

  15. Headlines GP pay soars by 30 per cent to £106,000 average Bumper GP Contracts 'Bad For Taxpayers' Government defends GP pay after press reports Report faults GP pay contract as 'poor deal'

  16. Unintended consequences • Pay increased 58 % (from £72,011 in 2002-03 to £113,614 in 2005-06), hours reduced • Low pay rise for other staff in practice • Media headlines • Breakdown of trust

  17. Unintended consequences • ‘Greedy/underworked doctors’ • ‘Foolish government’ • Government defensive • Pressure on medical profession • Loss of patient’s agenda

  18. Changing nature of incentive regime • Squeeze more from doctors • Higher minimum thresholds (2006) • Higher maximum achievement thresholds • New clinical areas ‘recycle’ points • Extended hours – 2 unpalatable options • Political pressure as opposed to evidence base • Retiring indicators

  19. Design & Implementation • Baseline • Measures • Retiring indicators • Rewards • Data collection & reporting • Trust (exception reporting) • Ground rules

  20. Thank you

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