Quality of Care in the United Kingdom after Removal of Financial Incentives

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Abstract

The benefits of pay-for-performance schemes in improving the quality of care remain uncertain. There is little information on the effect of removing incentives from existing pay-for-performance schemes.

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Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review.

S Gillam, A. Siriwardena, N Steel (2012)

Primary care practices in the United Kingdom have received substantial financial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This article reviews the growing evidence for the impact of the framework on the quality of primary medical care. Five hundred seventy-five articles were identified by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modified Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review. Quality of care for incentivized conditions during the first year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients' satisfaction with continuity declined, with little change in other domains of patient experience. Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefits of similar schemes.

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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.

Tim Doran, Catherine Fullwood, Evangelos Kontopantelis … (2008)

The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme. We analysed data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004-05 to 2006-07). Median overall reported achievement was 85.1% (IQR 79.0-89.1) in year 1, 89.3% (86.0-91.5) in year 2, and 90.8% (88.5-92.6) in year 3. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86.8% (82.2-89.6) for quintile 1 (least deprived) to 82.8% (75.2-87.8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4.4% for quintile 1 and by 7.6% for quintile 5, and the gap in median achievement narrowed from 4.0% to 0.8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0.0001), but was not associated with area deprivation (p=0.062). Our results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation.

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Pay for performance in health care: an international overview of initiatives.

Frank Eijkenaar (2012)

Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.

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Journal

Title: New England Journal of Medicine

Abbreviated Title: N Engl J Med

Publisher: New England Journal of Medicine (NEJM/MMS)

ISSN (Print): 0028-4793

ISSN (Electronic): 1533-4406

Publication date Created: September 06 2018

Publication date (Print): September 06 2018

Volume: 379

Issue: 10

Pages: 948-957

Affiliations

[1 ]From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) — all in the United Kingdom.

Article

DOI: 10.1056/NEJMsa1801495

PubMed ID: 30184445

SO-VID: df4ac89f-6ac9-40f0-9342-6ec1b130fc8e

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Quality of Care in the United Kingdom after Removal of Financial Incentives

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Most cited references 11

Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review.

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.

Pay for performance in health care: an international overview of initiatives.

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