1. Improving quality of care: has Denmark anything to learn from the UK? Martin Roland National Primary Care Research and Development Centre University of Manchester UK

2. How should doctors be paid? 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

3. Dramatis Personae

4. Content of presentation Variation in practice: the need for quality improvement in general practice What does research tell us about what makes a difference to quality of care UK government initiatives 1998-2003 – did they make a difference? Quality related pay 2003-2006 – intended and unintended consequences

5. Hypertensives with controlled BP 20% - 90% Diabetics with HbA1 in last year 25% - 100% Seddon ME et al. Quality in Health Care 2001; 10: 152. Variation in quality of primary care: systematic review of literature from UK, Australia and New Zealand

7. “In acute diseases, doctors differ so much among themselves that a treatment which one thinks the best possible, another thinks is bad Hippocrates 460-377BC … and similar differences are to be found in the examination of intestines.”

8. Good practice allowance – first suggested in the UK in 1986 The conference said “No” to a Good Practice Allowance. Dr Wilson said that the Good Practice Allowance was political and provocative. It was prepared by a government who only listened to philosophers and trendy professors. Report from the British Medical Association BMJ 1986; 293: 1384-6

9. 1980s Quality can’t be measured There’s no such thing as a bad doctor

10. 1990s in the UK A decade of quality improvement initiatives, mainly from government. But what improves quality? Were the initiatives evidence based?

11. 100% quality % quality achieved 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 Contracts Public release Patient safety Collaboratives Inspection

12. Quality of care in the UK improved between 1998 and 2003 Quality of care in 42 representative English practices. Campbell et al. BMJ 2005; 331: 1121-1123.

13. Quality of care improved between 1998 and 2003 (patients with coronary heart disease) Quality of care in 42 representative English practices. Campbell et al. BMJ 2005; 331: 1121-1123.

14. 1980s Quality can’t be measured There’s no such thing as a bad doctor 2000 Care is too variable Quality can be measured Care can be improved It’s expensive to provide high quality care “We want to be paid and given resources for providing high quality care”

15. 2003 UK pay for performance scheme “Quality and outcomes framework” 25% of GPs’ income relates to a complex set of 136 quality indicators £1.8 billion additional funding

16. King Hammurabi B.C.1795-1750

18. “If a doctor has opened an abscess of the eye and has cured the eye, he shall take ten shekels of silver”

19. “If a doctor has opened an abscess of the eye and has caused the loss of the eye, the doctor’s fingers shall be cut off”

20. 25% of income relating to 136 quality indicators Chronic disease management (Ten conditions) Practice organisation (Five areas) Patient experience New contract for GPs: Quality and Outcomes Framework Roland M. NEJM 2004; 351: 1448-54.

21. Seventy six clinical indicators covering: Coronary heart disease and heart failure (15) Stroke and transient ischaemic attack (10) Hypertension (5) Diabetes (18) Epilepsy (4) Hypothyroidism (2) Mental health (5) Asthma (7) Chronic obstructive pulmonary disease (8) Cancer (2) Roland M. NEJM 2004; 351: 1448-54.

22. 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 total cholesterol (measured in the last 15 months) is 190mg/dL or less Point score: from 1 point (25%) to 16 points (60%) Roland M. NEJM 2004; 351: 1448-54.

23. Exception reporting for clinical indicators Patient refused Not clinically appropriate Newly diagnosed or recently registered Already on maximum doses of medication Roland M. NEJM 2004; 351: 1448-54.

24. 56 organisational indicators: Records (19) Information to patients (8) Education and training (9) Practice management (10) Medicines management (10)

25. 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)

26. What are the effects of this type of financial incentive likely to be?

27. What might the effects be? Improved care Increased computerization / admin. costs More nurses, larger teams Fragmentation, less holistic approach Un-incentivized areas get worse care Gaming or misrepresentation Change in professional values

28. Practice performance in first year of new contract Quality points per practice, out of a maximum of 1050 www.ic.nhs.uk/services/qof

29. Quality of care improved further between 2003 and 2005, following the introduction of financial incentives 2005 data extends the time series in 42 representative practices reported by Campbell et al. BMJ 2005; 331: 1121-1123.

30. What might the effects be? Improved care Increased computerization / admin. costs More nurses, larger teams Fragmentation, less holistic approach Un-incentivized areas get worse care Gaming or misrepresentation Change in professional values

31. What might the effects be? Improved care Increased computerization / admin. costs More nurses, larger teams Fragmentation, less holistic approach Un-incentivized areas get worse care Gaming or misrepresentation Change in professional values

34. What might the effects be? Improved care Increased computerization / admin. costs More nurses, larger teams Fragmentation, less holistic approach Un-incentivized areas get worse care Gaming or misrepresentation Change in professional values

36. “There are some doctors who are more interested in the disease than the patient. It seems a funny sort of attitude to me.”

37. What might the effects be? Improved care Increased computerization / admin. costs More nurses, larger teams Fragmentation, less holistic approach Un-incentivized areas get worse care Gaming or misrepresentation Change in professional values

38. Example of an unintended outcome Indicator: Patients should be able to make an appointment to see a doctor within 48 hours Response: Advanced Access – offer unlimited appointments ‘on the day’ Consequence: Patients are unable to book ahead, and can only book on the day 2006: new and more sophisticated indicator, based on patient questionnaire scores

40. The ward was full, so I put him in my room as he was moribund and screaming and I did not want to wake the ward. I examined him. He had obvious gross bilateral cavitation and a severe pleural rub. I thought the latter was the cause of the pain and screaming. I had no morphia, just aspirin, which had no effect. I felt desperate. I knew very little Russian and there was no-one on the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming, but loneliness. I was ashamed of my misdiagnosis and kept my story secret. Archie Cochrane. One man’s medicine: an autobiography.

41. What might the effects be? Improved care Increased computerization / admin. costs More nurses, larger teams Fragmentation, less holistic approach Un-incentivized areas get worse care Gaming or misrepresentation Change in professional values

42. Exception reporting for clinical indicators Patient refused Not clinically appropriate Newly diagnosed or recently registered Already on maximum doses of medication Roland M. NEJM 2004; 351: 1448-54.

43. IQR = inter-quartile range Estimated exception reporting rates Doran et al. NEJM 2006; 355:375-384 Overall median5.4% Range0% - 85.8% n=8105 practices in England

45. What might the effects be? Improved care Increased computerization / admin. costs More nurses, larger teams Fragmentation, less holistic approach Un-incentivized areas get worse care Gaming or misrepresentation Change in professional values

46. “It will not provide the care for the whole person. It doesn’t allow that I have sat in this chair for over twenty years and I know my patients really well. It doesn’t allow for that. You can’t count that…and you can’t count the caring element” [GP16] Roland M, Campbell S, Bailey N, Whalley D, Sibbald B. Primary Health Care Research and Development 2006; 7: 70-78

47. They (the GPs) forget we’re actually nurses. You’ve not stopped all day because you have had ill patients. And then they come in and tell you that you are 1% down on a target Practice Nurse

48. “We developed this zero tolerance of blood pressure. No-one is allowed to say ‘It’s a little bit up, leave it’ …. it’s not acceptable.” Senior GP

49. “When we’re not meeting a target, I will go in and speak to them privately. I did do one area of naming and shaming … that did work quite well …they don’t want to be seen as the GP who’s falling down.” Senior GP, talking about other GPs in his practice

50. I enjoy being given the autonomy to manage the different diseases…. because we are actually meeting targets, patient care has definitely improved Practice Nurse

51. Mercifully we’ve been able to put the clock back … and get back to the people agenda [GP2] Roland M, Campbell S, Bailey N, Whalley D, Sibbald B. Primary Health Care Research and Development 2006; 7: 70-78

52. Changes in GP job satisfaction 1989-2005 Major reform

53. How should doctors be paid? 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

55. Health impact of financial 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: 191-197

56. “I thought you were supposed to tailor care to every individual patient. I think it takes away patient centered care. I don’t think people appreciate being phoned up all the time to be reminded to come in for checks.” (Practice Nurse)

57. Percentage of practices reaching 80% cervical cytology target Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423

58. Percentage of practices reaching 80% cervical cytology target Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423

59. Changes in management of coronary heart disease 1998-2003 Campbell et al. British Medical Journal 2005; 331: 1121-1123.

60. Quality of care for individuals is determined by: Access (can the patient get to care?) Effectiveness (is it any good when he / she does?) - clinical care - interpersonal aspects of care Quality for populations is determined in addition by: Equity Efficiency Campbell S, Roland M, Buetow S. Defining Quality of Care. Social Science and Medicine 2000; 51: 1611-1625.