Linking 25% of UK FPs pay to quality of care: a major experiment in quality improvement Martin Roland Director National Primary Care Research and Development Centre University of Manchester UK

100% quality Baseline quality Guidelines Audit / feedback Opinion leaders Financial incentives ? All of these things - no magic bullet Major UK initiatives National standards Clinical governance Annual appraisal Public release Patient safety Collaboratives Inspection Contracts

With one mighty leap, the NHS vaults over anything being attempted in the United States, the previous leader in quality improvement initiatives. Shekelle P. British Medical Journal (editorial) 2003; 326: 457-8

1980s Quality cant be measured Theres no such thing as a bad doctor 2002 Care is too variable Quality can be measured Care can be improved Its expensive to provide high quality care We want to be resourced and rewarded for providing high quality care Changes in doctors views

Health care quality = electoral liability Methods of measuring quality Cultural shift: Quality needs to be improved + opportunity for increased income Quality incentive scheme offering up to 25% increased income to FPs Collaboration between Government Academics Physicians

New FP contract: Quality and Outcomes Framework 25% of income from quality incentives Chronic disease management (Ten conditions) Practice organisation (Five areas) Patient experience Roland M. Linking physician pay to quality of care. New England Journal of Medicine 2004; 351:

Seventy six clinical indicators covering: Coronary heart disease and heart failure (15) Stroke and transient ischemic attack (10) Hypertension (5) Diabetes (18) Epilepsy (4) Hypothyroidism (2) Mental health (5) Asthma (7) Chronic obstructive pulmonary disease (8) Cancer (2)

CHD 7. The percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months. Point score: from 1 point (25%) to 7 points (90%) CHD 8. The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the last 15 months) is 290mg/dl or less Point score: from 1 point (25%) to 16 points (60%)

Exception reporting for clinical indicators Patient refused / not attended despite three reminders Not appropriate e.g. supervening clinical condition, extreme frailty, adverse reaction to medication, contraindication etc Newly diagnosed or recently registered Already on maximum tolerated doses of medication Investigative service is unavailable

56 organisational indicators: Records (19) Information to patients (8) Education and training (9) Practice management (10) Medicines management (10)

Examples of organisational indicators Records Smoking status is recorded for 75% of patients between 15 and 75 Medicines management A medication review is recorded in the preceding 15 months for 80% of patients who receive regular prescriptions but do not need to see the physician each time

Four indicators relating to patient experience: Conducting and acting on the results of patient surveys (3) Booking consultations intervals of 10 minutes or more (1)

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

Potential health impact of new incentives Impact of increasing quality of care from present levels to highest levels specified in contract No of cardiovascular events prevented per 5 years per 10,000 Cholesterol lowering in CHD15.5 Blood pressure control in Hypertension15.4 McElduff P. et al. Will changes in primary care improve health outcomes. Quality and Safety in Health Care 2004; 13:

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

Percentage of practices reaching 80% cervical cytology target Baker et al. J. Epidemiology and Community Health 2003; 57:

Percentage of practices reaching 80% cervical cytology target Baker et al. J. Epidemiology and Community Health 2003; 57:

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

What might the effects be? Increased computerization / admin costs More nurses, larger teams, more specialization Improved health outcomes Reduced health inequalities More medicalization, less holistic approach Worse care for un-incentivized conditions Gaming or misrepresentation Change in professional motivation

The inter-personal side is going to go because the ticks in boxes are going to be all thats important..... itll be the death of generalism and holistic care … The idea of putting the resources where the morbidity is strikes me as a big advance … and Im only sorry that it has been softened by the bleatings of those whove had it too soft for too long My collective noun for GPs is a grasp of GPs

Early results – Scotland % of maximum available points scored % of practices Total points scored

Salary Do as little as possible for as few people as possible CapitationDo as little as possible for as many people as possible FFSDo as much as possible, whether or not it helps the patient Quality Carry out a limited range of highly commendabletasks, but nothing else Paying physicians: economic theory

Changes in management of diabetes