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.

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

GuidelinesAudit / 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 can’t be measured• There’s no such thing as a bad doctor

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

Changes in doctors’ views 1980-2002

• 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: 1448-54.

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 managementA 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



















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 CHD 15.5 Blood pressure control in Hypertension 15.4

McElduff P. et al. Will changes in primary care improve health outcomes. Quality and Safety in Health Care 2004; 13: 191-197










50

60

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100

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

50

60

70

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100

1991 1992 1993 1994 1995 1996 1997 1998 1999

AffluentareasDeprivedareas

Percentage of practices reaching 80% cervical cytology target

Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423





































“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”

“My collective noun for GPs is a grasp of GPs”

Early results – Scotland% of maximum available points scored

010

2030

4050

% o

f pra

ctic

es

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100Total points scored

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

Paying physicians: economic theory

Changes in management of diabetes 1998-2003

0

10

20

30

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50

60

Serum cholesterol5mmol/l or less

BP 150/90 or less HbA1c <7.4%

1998 2003

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.

Documents

health care quality

unavailable slide

time slide

quality needs

variable quality

s quality

high quality care changes

health inequalities