Linking 25% of UK FP’s 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
these things
MajorAll
UK of
initiatives
• National
- nostandards
magic bullet
• Clinical governance
• Annual appraisal
• Public release
• Patient safety
• Collaboratives
• Inspection
• Contracts
?
Guidelines
Audit /
feedback
Opinion
leaders
Financial
incentives
Changes in doctors’ views 1980-2002
“With one mighty leap, the NHS vaults
over anything being attempted in the
1980s
• Quality can’t be measured
• There’s no such thing as a bad doctor
United States, the previous leader in
quality improvement initiatives.”
Shekelle P. British Medical Journal
(editorial) 2003; 326: 457-8
2002
• Care is too variable
• Quality can be measured
• Care can be improved
• It’s expensive to provide high quality care
• We want to be resourced and rewarded for
providing high quality care
Quality incentive scheme offering up to
25% increased income to FPs
New FP contract:
Quality and Outcomes Framework
Collaboration between
25% of income from quality incentives
• Chronic disease management
•Government
• Health care quality = electoral
liability
•Academics
• Methods of measuring quality
• Practice organisation
• Cultural shift: Quality needs
to be improved + opportunity
for increased income
• Patient experience
•Physicians
(Ten conditions)
(Five areas)
Roland M. Linking physician pay to quality of care.
New England Journal of Medicine 2004; 351: 1448-54.
1
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
56 organisational indicators:
• Patient refused / not attended despite three
reminders
Records (19)
• Not appropriate e.g. supervening clinical
condition, extreme frailty, adverse reaction to
medication, contraindication etc
Information to patients (8)
Education and training (9)
• Newly diagnosed or recently registered
• Already on maximum tolerated doses of
medication
Practice management (10)
Medicines management (10)
• Investigative service is unavailable
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)
2
What might the effects be?
What might the effects be?
• Increased computerization / admin costs
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• More nurses, larger teams, more specialization
• Improved health outcomes
• Improved health outcomes
• Reduced health inequalities
• Reduced health inequalities
• More medicalization, less holistic approach
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Gaming or misrepresentation
• Change in professional motivation
• Change in professional motivation
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
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
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
Cholesterol lowering in CHD
15.5
• Worse care for un-incentivized conditions
Blood pressure control in Hypertension
15.4
• Gaming or misrepresentation
• Change in professional motivation
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
McElduff P. et al. Will changes in primary care improve health
outcomes. Quality and Safety in Health Care 2004; 13: 191-197
100
90
80
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
70
60
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
50
1991 1992 1993 1994 1995 1996 1997 1998 1999
Percentage of practices reaching 80% cervical cytology target
Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423
3
What might the effects be?
100
90
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
80
Affluent
areas
Deprived
areas
70
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
60
• Worse care for un-incentivized conditions
50
1991 1992 1993 1994 1995 1996 1997 1998 1999
Percentage of practices reaching 80% cervical cytology target
• Gaming or misrepresentation
• Change in professional motivation
Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423
What might the effects be?
What might the effects be?
• Increased computerization / admin costs
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• More nurses, larger teams, more specialization
• Improved health outcomes
• Improved health outcomes
• Reduced health inequalities
• Reduced health inequalities
• More medicalization, less holistic approach
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Gaming or misrepresentation
• Change in professional motivation
• 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
“My collective noun for GPs is a grasp
of GPs”
“The inter-personal side is going to go
because the ticks in boxes are going to be
all that’s important ..... it’ll 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 I’m only sorry that it has been
softened by the bleatings of those who’ve
had it too soft for too long”
4
Paying physicians: economic theory
Salary
Do as little as possible for as
few people as possible
Capitation
Do as little as possible for as
many people as possible
FFS
Do as much as possible, whether or
not it helps the patient
Quality
Carry out a limited range of highly
commendable tasks, but nothing else
0
10
% of practices
20
30
40
50
Early results – Scotland
% of maximum available points scored
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Total points scored
Changes in management of diabetes
1998-2003
60
50
40
30
20
10
0
Serum cholesterol
5mmol/l or less
BP 150/90 or less
1998
HbA1c <7.4%
2003
5