1. Doran Quality of primary care under the UK pay-for-performance scheme T Doran, C Fullwood, E Kontopantelis, D Reeves, J Valderas, S Campbell, M Roland National Primary Care Research and Development Centre University of Manchester CEO Forum Kananaskis, 16 February 2009 Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF

2. Outline Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF 1.The UK pay-for-performance scheme Background The Quality and Outcomes Framework 2.Results from Years 1-4 (2004-05 to 2007-08) Overview Achievement of targets Inequalities in quality of care 3.Quality of care before and after the introduction of P4P Identification of cases Achievement of process indicators Achievement of intermediate outcomes indicators Quality of care for non-incentivised activities

3. Outline Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF 1.The UK pay-for-performance scheme Background The Quality and Outcomes Framework 2.Results from Years 1-4 (2004-05 to 2007-08) Overview Achievement of targets Inequalities in quality of care 3.Quality of care before and after the introduction of P4P Identification of cases Achievement of process indicators Achievement of intermediate outcomes indicators Quality of care for non-incentivised activities Background The Quality and Outcomes Framework

4. Background Improving quality of UK primary care in the late 1990s Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF o Recognition of the need for quality improvement Acknowledgement of poor quality care by medical profession Recognition of health inequalities by Government Prioritisation of quality improvement initiatives by Department of Health (DH) o Additional funding for health services Government increased funding to NHS -£69bn (C$130bn) in 2004  £92bn (C$175bn) in 2008 DH determined to address low morale in primary care o Quality improvement initiatives National Service Frameworks for major chronic diseases Audit, inspection and revalidation of doctors Public release of outcomes data Computerisation of patient records Background The Quality and Outcomes Framework

5. The Quality and Outcomes Framework (QOF) The original framework Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF o Introduced in April 2004 for all practices in the UK o Family practitioner income increased by ~ 25% dependent on performance against 146 quality indicators o Each indicator allocated between 0.5 and 56 points (1,050 in total) o Each point earns an average practice £76 (C$144) o Maximum of £79,800 (C$151,600) per practice £25,000 (C$47,500) per physician o Achievement scores are publicly reported www.qof.ic.nhs.uk Background The Quality and Outcomes Framework

6. The quality indicators Clinical indicators Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework Disease areaIndicatorsPoints asthma772 cancer212 chronic obstructive pulmonary disease845 coronary heart disease15121 diabetes1899 epilepsy416 hypertension5105 hypothyroidism28 mental health541 stroke1031 total76550

7. The quality indicators Organisational indicators Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework ActivityIndicatorsPoints Organisation of care56184 record keeping1985 patient communication88 education and training929 practice management1020 medicines management1042 Patient experience4100 Additional services1036 Access---50 Overall quality---30 Holistic care---100 total70500

8. New indicators for Year 3 (2006-07) Clinical indicators Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework Disease areaIndicatorsPoints atrial fibrillation330 chronic kidney disease427 dementia220 depression233 learning difficulties14 obesity18 palliative care26 (smoking268) total15128

9. Achievement thresholds CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework Minimum threshold Maximum threshold Points: 0 to 19 points Income: £0 to £1,444 (C$ 2,744)

10. Protecting patients against inappropriate treatment Exception reporting Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF o Physicians may exclude (‘exception report’) patients for whom targets are inappropriate o Discretionary exception reporting: treatment not tolerated patient terminally ill, exceptionally frail or has supervening condition o Non-discretionary exception reporting: patient refuses intervention or repeatedly refuses to attend patient newly registered or diagnosed service not available to practice Background The Quality and Outcomes Framework

11. Outline Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF 1.The UK pay-for-performance scheme Background The Quality and Outcomes Framework 2.Results from Years 1-4 (2004-05 to 2007-08) Overview Achievement of targets Inequalities in quality of care 3.Quality of care before and after the introduction of P4P Identification of cases Achievement of process indicators Achievement of intermediate outcomes indicators Quality of care for non-incentivised activities Overview Achievement of targets Inequalities in quality of care

12. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care NHS Information Centre (www.qof.ic.nhs.uk) Year% of total points scored % of clinical points scored Mean earnings per physician 2004-0591.3%92.4%£22,750 (C$ 43,225) 2005-0696.3%97.1%£39,490 (C$ 75,030) 2006-0795.5%96.3%£37,300 (C$ 70,870) 2007-0896.8%97.5%£37,800 (C$ 71,820) Results for Years 1-4 Points scored and remuneration

13. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Achievement of clinical targets Overall achievement for 50 ‘stable’ indicators Doran Number of practices Percentage achievement Mean: Year 1 82.3% Year 2 87.8% Year 3 89.7% Year 4 90.0%

14. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Exclusion of patients Overall exception reporting rates for 50 ‘stable’ indicators Doran Percentage excluded Number of practices Mean: Year 2 7.1% Year 3 7.8% Year 4 7.1%

15. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Inequality in quality of care Achievement by area deprivation quintile Doran et al. Lancet 2008; 372: 728-736. 2004-052005-062006-07 Reported achievement

16. Outline Doran Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF 1.The UK pay-for-performance scheme Background The Quality and Outcomes Framework 2.Results from Years 1-4 (2004-05 to 2007-08) Overview Achievement of targets Inequalities in quality of care 3.Quality of care before and after the introduction of P4P Identification of cases Achievement of process indicators Achievement of intermediate outcomes indicators Quality of care for non-incentivised activities Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities

17. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities Incentivised process DM4: Smoking advice offered in previous 15 months (5 points) Doran

18. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities Incentivised process DM11: Record of blood pressure in previous 15 months (3 points) Doran

19. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities Incentivised intermediate outcome DM12: Last recorded blood pressure is ≤ 145/85 mmHg (17 points) Doran

20. Quality of care under the UK P4P scheme UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities Non-incentivised patient group Record of blood pressure in last 15m, all patients aged 25-44 Doran

21. Summary Intended outcomes of the QOF Doran Quality of care under the UK P4P scheme Summary o Improving quality of care Achievement for most incentivised activities increased over the first 3 years, but there was little improvement in Year 4 Improvement over underlying trend for processes with low baseline Marginal improvement over trend for outcomes activities o Reducing variations in quality of care The poorest performing practices improved at the fastest rate Overall inequalities in quality of care for incentivised activities almost disappeared by Year 3 o Keeping physicians happy Over 4,000 additional physicians recruited (15% increase) Income of principals increased by 58% (£41,600/ C$79,000) Income of salaried physicians increased by 3% (£2,200/ C$4,200) Intended outcomes Unintended outcomes Conclusions

22. Summary Unintended outcomes of the QOF Doran Quality of care under the UK P4P scheme Summary o Reducing quality of care Quality of care for non-incentivised activities may have declined after the introduction of the QOF o Excluding patients Practices in deprived areas excluded marginally more patients Some practices struggling to hit maximum achievement thresholds inappropriately excluded patients in order to maximise income Some practices removed patients from chronic disease registers Patients have had little input to the QOF to date o Reducing staff morale Pressure on staff to hit QOF targets has caused some dissatisfaction Rewards from QOF have not been equitably distributed Intended outcomes Unintended outcomes Conclusions

23. Lessons from the UK’s experiment with pay-for-performance Doran Quality of care under the UK P4P scheme Summary o Put the necessary infrastructure in place Installation of computing systems subsidised by Government Several years of audit and quality improvement preceded the QOF o Get physicians on-side Indicators based on evidence (or at least expert opinion) Generous remuneration for achieving targets o Establish a baseline Quality of care was already improving when QOF introduced Most practices were already achieving above the maximum thresholds o Regularly review the framework and the indicators QOF reviewed and indicators updated every 1-2 years In future the cost-effectiveness of indicators will be assessed by the National Institute for Health and Clinical Excellence (NICE) Potential new indicators will be piloted Local QOFs will be introduced to address local priorities Intended outcomes Unintended outcomes Conclusions

24. Further reading Resources and papers on the UK QOF Doran Quality of care under the UK P4P scheme o Resources Department of Health. The Quality and Outcomes Framework. Available from: http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/index.htm http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/index.htm The NHS Information Centre. Online GP Practice Results Database. Available from: http://www.qof.ic.nhs.uk/http://www.qof.ic.nhs.uk/ o Published research Ashworth M, Seed P, Armstrong D, Durbaba S, Jones R. The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework. British Journal of General Practice 2007: 57: 441-448. Campbell S, Reeves D, Kontopantelis E, et al. Quality of primary care in England with the introduction of pay for performance. New England Journal of Medicine 2007; 351: 181-190. Doran T, Fullwood C, Gravelle H, et al. Pay for performance programs in family practices in the United Kingdom. New England Journal of Medicine 2006; 355: 375-384. Doran T, Fullwood C, Reeves D, et al. Exclusion of patients from pay-for-performance targets by English physicians. New England Journal of Medicine 2008; 359: 274-284. Doran T, Fullwood C, Kontopantelis E, Reeves D. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet 2008; 372: 728-736. Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: further evidence from the quality and outcomes framework. CHE Research Paper 32. York: Centre for Health Economics, 2008. Gray J, Millett C, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnicity and quality of diabetes care in a health system with universal coverage: population-based cross sectional survey in primary care. J Gen Intern Med. 2007; 22(9): 1317-1320. Guthrie B, McLean G, Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. British Journal of General Practice. 2006; 56: 836-841. McDonald R, Harrison S, Checkland K, Campbell S, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. British Medical Journal 2007; 334: 1357-1362. Roland M. Linking physicians’ pay to the quality of care – a major experiment in the United Kingdom. New England Journal of Medicine. 2004; 351: 1448-1454. Further reading UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF

25. Further information: tim.doran@manchester.ac.uk Doran UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Quality of care under the UK P4P scheme