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

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