TIM DORANUNIVERSITY OF YORK
EQUITY IN PRIMARY CARE
PAYING FOR PERFORMANCE
HEALTH INEQUALITYIMPACT OF PRIMARY CARE PAYING FOR PERFORMANCE
HEALTH INEQUALITIES IN ENGLAND
SOURCE: DORLING ET AL, GRIM REAPER’S ROAD MAP, BRISTOL 2008 PRIMARY CARE AND HEALTH DISPARITY
HEALTH INEQUALITYIMPACT OF PRIMARY CARE PAYING FOR PERFORMANCE
1948: THE NATIONAL HEALTH SERVICE
BEVERIDGE AND THE FIVE GIANTS PRIMARY CARE AND HEALTH DISPARITY
PRIMARY CARE UNDER THE NHS
SOURCE: COLLINGS, LANCET 1950; 6625: 555-585. PRIMARY CARE AND HEALTH DISPARITY
“Conditions are… bad enough to turn a good doctor into a bad one within a very short
time.”
“…at best… very unsatisfactory and at worst a positive source of public danger.”
REPEALING THE INVERSE CARE LAW
SOURCE: TUDOR HART ET AL, BMJ 1991; 302: 1509-1503. PRIMARY CARE AND HEALTH DISPARITY
GLYNCORRWGPOPULATION 190064% UNSKILLED
HEALTH CENTRE‘SCREENING’ FOR BP, SMOKING, CHOLESTEROL, DIABETES, LUNG FUNCTION, BMI, ALCOHOLISM
MORTALITY SMR 94 (-6%)(BLAENGWYNFI 16O)
HEALTH INEQUALITYIMPACT OF PRIMARY CARE PAYING FOR PERFORMANCE
QUALITY & OUTCOMES FRAMEWORK
OVERVIEW OF THE QUALITY & OUTCOMES FRAMEWORK PRIMARY CARE AND HEALTH DISPARITY
INTRODUCED 2004 (ALL UK GENERAL PRACTICES)
146 QUALITY INDICATORS COVERING:
• MANAGEMENT OF CHRONIC CONDITIONS
• ORGANISATION OF CARE
• PATIENT EXPERIENCE
INDICATORS WORTH 0.5-57 POINTS (TOTAL 1,000)
• 1 POINT = £125 (€145)
PRACTICES EXCLUDE INAPPROPRIATE PATIENTS
ACHIEVEMENT SCORES PUBLICLY REPORTED
E.G.: CONTROL OF BLOOD PRESSURE
CHD6: PERCENTAGE OF CHD PATIENTS WITH BP ≤150/90 MMHG PRIMARY CARE AND HEALTH DISPARITY
0 3 6 9 1215182124273033363942454851545760636669727578818487909396990
2
4
6
8
10
12
14
16
18
20
Percentage achievement
PO
INTS S
CO
RED
PERCENTAGE ACHIEVEMENT
LOWER THRESHOLD
UPPER THRESHOLD
POINTS: 0-19
PAYMENT: £0-1,444
IMPACT ON INEQUALITIES
SOURCE: DORAN ET AL. LANCET 2008; 372: 728-736.
REPO
RTED
AC
HIE
VEM
EN
T
2004/5 2005/6 2006/7
PRIMARY CARE AND HEALTH DISPARITY
IMPACT ON INEQUALITIES
DIABETES INDICATORS, BY DEPRIVATION QUINTILE PRIMARY CARE AND HEALTH DISPARITY
AC
HIE
VEM
EN
T
DEPRIVATION QUINTILE
PROCESSES OUTCOMES
NON-INCENTIVIZED ACTIVITIES
SOURCE: DORAN ET AL. BMJ 2011; 342: D3590.
AC
HIE
VEM
EN
T A
BO
VE P
RED
ICTED
PRIMARY CARE AND HEALTH DISPARITY
2004/5 2006/7
NO EFFECT
SYSTEM ADVANTAGES
ADDITIONAL REMUNERATION COMPARED WITH SYSTEM ‘G’
RELA
TIV
E G
AIN
PRIMARY CARE AND HEALTH DISPARITY
COMPUTING SYSTEM
VIEWS OF PRACTITIONERS
SOURCE: WEHRLI U, FUR ELISE PRIMARY CARE AND HEALTH DISPARITY
“It's a good idea – I think it makes things tangible and quantifies things…”
“…although I hate it. I do.”
SOURCE: MCDONALD ET AL. BMJ 2007; 334: 1357-1362. PRIMARY CARE AND HEALTH DISPARITY
EQUITABLE CARE PROVISION?
PRIMARY CARE AND HEALTH DISPARITY
PATIE
NTS
PER
PH
YSIC
IAN
DEPRIVATION ‘DECILE’
DISTRIBUTION OF PRIMARY CARE PHYSICIANS (1996)
