Effect of a UK pay-for-performance program on ethnic disparities in diabetes outcomes: interrupted time series analysis

PURPOSE

We wanted to examine the long-term effects of the Quality and Outcomes Framework (QOF), a major pay-for-performance program in the United Kingdom, on ethnic disparities in diabetes outcomes.

METHODS

We undertook an interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London, United Kingdom. Main outcome measures were mean hemoglobin A_1c (HbA_1c), total cholesterol, and blood pressure.

RESULTS

The introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients (annual decrease: −1.68 mm Hg; 95% CI, −2.41 to −0.95 mm Hg). Initial improvements in diastolic blood pressure in white patients (−1.01 mm Hg; 95% CI, −1.79 to −0.24 mm Hg) and in cholesterol in white (−0.13 mmol/L; 95% CI, −0.21 to −0.05 mmol/L) and black (−0.10 mmol/L; 95% CI, −0.20 to −0.01 mmol/L) patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA_1c in any ethnic group. Existing disparities in risk factor control remained largely intact (for example; mean HbA_1c: white 7.5%, black 7.8%, south Asian 7.8%; P <.05) at the end of the study period.

CONCLUSION

A universal pay-for-performance scheme did not appear to address important disparities in chronic disease management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.     

Pay-for-performance: too much of a good thing? A conversation with Martin Roland. Interview by Robert Galvin

As the United States moves down the road of pay-for-performance (P4P), concerns about unintended consequences are foremost in the minds of policymakers. Initial results from the world's most ambitious P4P program, the United Kingdom's Quality and Outcomes Framework (QOF), indicate that while quality improvements exceeded expectations, so too did the amount of funds paid out, straining the National Health Service (NHS) budget. Martin Roland, one of the leading U.K. health services researchers and an adviser to the QOF, gives his views on what went right and what went wrong, and he offers his advice to the United States about using financial incentives to improve quality.     

The impact of pay-for-performance on professional boundaries in UK general practice: an ethnographic study

The 2004 new General Medical Services (nGMS) contract exemplifies trends across the public services towards increased definition, measurement and regulation of professional work, with general practice income now largely dependent on the quality of care provided across a range of clinical and organisational indicators known collectively as the 'Quality and Outcomes Framework' (QOF). This paper reports an ethnographically based study of the impact of the new contract and the financial incentives contained within it on professional boundaries in UK general practice. The distribution of clinical and administrative work has changed significantly and there has been a new concentration of authority, with QOF decision making and monitoring being led by an internal QOF team of clinical and managerial staff who make the major practice-level decisions about QOF, monitor progress against targets, and intervene to resolve areas or indicators at risk of missing targets. General practitioners and nurses, however, appear to have accommodated these changes by re-creating long established narratives on professional boundaries and clinical hierarchies. This paper is concerned with the impact of these new arrangements on existing clinical hierarchies.     

Effects of payment for performance in primary care: qualitative interview study

OBJECTIVES: To understand the effects of a large scale 'payment for performance' scheme (the Quality and Outcomes Framework [QOF]) on professional roles and the delivery of primary care in the English National Health Service. METHODS: Qualitative semi-structured interview study. Twenty-four clinicians were interviewed during 2006: one general practitioner and one practice nurse in 12 general practices in eastern England with a broad range of sociodemographic and organizational characteristics. RESULTS: Participants reported substantial improvements in teamwork and in the organization, consistency and recording of care for conditions incentivized in the scheme, but not for non-incentivized conditions. The need to carry out and record specific clinical activities was felt to have changed the emphasis from 'patient led' consultations and listening to patients' concerns. Loss of continuity of care and of patient choice were described. Nurses experienced increased workload but enjoyed more autonomy and job satisfaction. Doctors acknowledged improved disease management and teamwork but expressed unease about 'box-ticking' and increased demands of team supervision, despite better terms and conditions. Doctors were less motivated to achieve performance indicators where they disputed the evidence on which they were based. Participants expressed little engagement with results of patient surveys or patient involvement initiatives. Some participants described data manipulation to maximize practice income. Many felt overwhelmed by the flow of policy initiatives. CONCLUSIONS: Payment for performance is driving major changes in the roles and organization of English primary health care teams. Non-incentivized activities and patients' concerns may receive less clinical attention. Practitioners would benefit from improved dissemination of the evidence justifying the inclusion of new performance indicators in the QOF.     

Primary medical care in the United kingdom

Since 1948 health care in the United Kingdom (UK) has been centrally funded through the National Health Service (NHS). The NHS provides both primary and specialist health care which is largely free at the point of delivery. Family practitioners are responsible for registered populations of patients and typically work in groups of 4-6 self-employed physicians. They hire nurses and a range of other ancillary staff, and act as gatekeepers to specialist care. Recent reforms include a wide range of national quality improvement initiatives and a pay for performance scheme that accounts for around 25% of family practitioners' income. These reforms have been associated with some major improvements in quality, including improved chronic disease management and reduced waiting times for specialist care. The four countries of the UK differ in some important aspects of health care organization: proposed reforms in England would move towards a more market-driven system, with family practitioners acting as payers for specialist care and controlling 70% of the NHS budget. The other countries (Scotland, Wales and Northern Ireland) focus more on trying to create area-based integrated systems of care.     

Socioeconomic deprivation, coronary heart disease prevalence and quality of care: a practice-level analysis in Rotherham using data from the new UK general practitioner Quality and Outcomes Framework

BACKGROUND: The provision of coronary heart disease (CHD) health care has been shown to be inequitous, with those most in need having the least access to high-quality care. The new UK general practitioner (GP) Quality and Outcomes Framework (QOF) contract offers substantial financial rewards to general practices that combine maximal CHD case finding with high-quality CHD care. OBJECTIVE: To examine whether GP practice-level CHD prevalence and the measures of quality of care derived from the new QOF data are associated with area-level socioeconomic deprivation. METHODS: An ecological study of 38 GP practices contracting with Rotherham Primary Care Trust, United Kingdom, was carried out. We calculated Spearman rank correlation coefficients for practice-level age-sex-standardized QOF CHD prevalence against area deprivation score and for 11 QOF CHD indicator achievements against area deprivation score. RESULTS: Practice-level CHD prevalence showed a positive correlation with deprivation (r=0.64, p<0.001), as did one of the 11 quality-of-care indicators (recording of smoking status, r=0.34, p=0.04). The remaining 10 quality-of-care indicators showed no significant correlation with deprivation. CONCLUSION: Practice-level CHD prevalence is associated with deprivation, but we found no evidence of socioeconomic inequality in CHD care. This finding is in contrast to that from previous studies and the widely reported inverse care law.     

Is primary care ready to take on Attention Deficit Hyperactivity Disorder?

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood psychiatric disorder. The management of ADHD has recently been highlighted. The National Institute of Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines network (SIGN) have both produced management guidelines. Doctors working within Primary Care in countries such as the United States play an important role in the management of ADHD. In the United Kingdom however the role of doctors in primary care in the management of ADHD, both individually and within shared care protocols, is only now being identified and defined. Is this role for Primary Care likely to be acceptable and effective?

Discussion

There is some evidence that doctors working within Primary Care in the United Kingdom are willing to follow up children on medication for ADHD and carry out monitoring of physical status. However many feel unconfident in the management of ADHD and most have received little or no training in child psychiatry. There are also concerns that adverse media reports will have an undue influence on the attitudes of doctors within primary care to families with children suffering from ADHD.

Summary

There are important barriers to be tackled before shared care protocols for ADHD can be successfully implemented in the United Kingdom. Tailored information about ADHD needs to be provided to doctors in primary care. Clear dialogue between planners and healthcare professionals from both primary and secondary care is essential to ensure that service delivery is acceptable to healthcare providers, tailored to their skills and is adequately resourced.

     

National health system steps in Turkey: concerns of family physician residents in Turkey regarding the proposed national family physician system

Many countries are currently struggling with the public desire for improved health care and provision of basic services on the one hand, and the rising costs of health care on the other. Turkey is acutely experiencing this problem because of its relatively advanced level of economic development and its relatively low level of health status compared to Organization for Economic Cooperation and Development and European Union countries. Since 1990, there has been vigorous debate in the Turkish society regarding the best way to improve public health through improved primary health care. The current government is pursuing a proposal that has been mentioned before, but in a more serious effort than has been previously made. This is an approach to primary care based on systems such as those in the United Kingdom and in Germany, and the basic components are family physicians who have a particular list of patients whom they provide care for. Financing of the system is to be provided with a new general health insurance scheme. In this study, 38 family practice residents at the 3 major training hospitals for this specialty completed an investigator-designed questionnaire for the purpose of characterizing their concerns regarding this proposed system of primary health care delivery. The participants' responses indicated that the new system, which is known as the Family Physician System, will contribute importantly toward raising the overall level of health in Turkey. Specific expected benefits include closer patient-physician relationships, increased job satisfaction on the part of family physicians, and an overall increase in income for the physicians working in the system.     

Non-physician providers of obstetric care in Mexico: Perspectives of physicians, obstetric nurses and professional midwives

Background

Economically developed countries have recruited large numbers of overseas health workers to fill domestic shortages. Recognition of the negative impact this can have on health care in developing countries led the United Kingdom Department of Health to issue a Code of Practice for National Health Service (NHS) employers in 1999 providing ethical guidance on international recruitment. Case reports suggest this guidance had limited influence in the context of other NHS policy priorities.

Methods

The temporal association between trends in new professional registrations from doctors qualifying overseas and relevant United Kingdom government policy is reported. Government policy documents were identified by a literature review; further information was obtained, when appropriate, through requests made under the Freedom of Information Act. Data on new professional registration of doctors were obtained from the General Medical Council (GMC).

Results

New United Kingdom professional registrations by doctors trained in Africa and south Asia more than doubled from 3105 in 2001 to 7343 in 2003, as NHS Trusts sought to achieve recruitment targets specified in the 2000 NHS Plan; this occurred despite ethical guidance to avoid active recruitment of doctors from resource-poor countries. Registration of such doctors declined subsequently, but in response to other government policy initiatives. A fall in registration of South African-trained doctors from 3206 in 2003 to 4 in 2004 followed a Memorandum of Understanding with South Africa signed in 2003. Registrations from India and Pakistan fell from a peak of 4626 in 2004 to 1169 in 2007 following changes in United Kingdom immigration law in 2005 and 2006. Since 2007, registration of new doctors trained outside the European Economic Area has remained relatively stable, but in 2010 the United Kingdom still registered 722 new doctors trained in Africa and 1207 trained in India and Pakistan.

Conclusions

Ethical guidance was ineffective in preventing mass registration by doctors trained in resource-poor countries between 2001 and 2004 because of competing NHS policy priorities. Changes in United Kingdom immigration laws and bilateral agreements have subsequently reduced new registrations, but about 4000 new doctors a year continue to register who trained in Africa, Asia and less economically developed European countries.     

Continuity and Trust in Primary Care: A Qualitative Study Informed by Game Theory

PURPOSE The relationship between continuity of care and patient trust in primary care is not fully understood. We report an empirical investigation, informed by game theory, of patients’ accounts of their trust in general practitioners (GPs).METHODS We conducted an analysis based on the constant comparative method of 20 semistructured interviews with patients about trust in GPs in the United Kingdom.RESULTS People use institutional trust, derived from expectations of medicine as an institution and doctors as professionals, as a starting point for their transactions with unfamiliar doctors. This expectation may be enough to allow patients the minimum of what they want from doctors and is often sufficient for single-episode encounters, where patients have specific goals. Repeated interactions with the same doctor can allow patients to develop more secure expectations, based on a history of other interactions and anticipation of future interactions. Secure trust can develop over time, especially if patients are convinced that the doctor has their interests at heart.CONCLUSIONS This work identifies dynamics inherent in repeated interactions that enable secure trust to develop. These findings have important implications for the design of services, which in the United Kingdom and elsewhere are increasingly focused on enhancing access rather than continuity. They suggest that patients do not see GPs as interchangeable and that the move toward organizing services around single encounters may disrupt the development of secure trust.     

The UK Quality and Outcomes Framework pay-for-performance scheme and spirometry: rewarding quality or just quantity? A cross-sectional study in Rotherham, UK

Background  

Accurate spirometry is important in the management of COPD. The UK Quality and Outcomes Framework pay-for-performance scheme for general practitioners includes spirometry related indicators within its COPD domain. It is not known whether high achievement against QOF spirometry indicators is associated with spirometry to BTS standards.     

Doctor-manager relationships in the United States and the United Kingdom

In many developed countries, including the United States and the United Kingdom, the relationships between doctors and hospital managers are strained. The purposes of this article are to examine survey data from the United States and the United Kingdom on doctor-manager relationships and to identify the sources of strain common to both countries as well as those particular to each country's health system. The two countries exhibited many similarities. A very high proportion of respondents from both countries identified external factors-such as governmental budget cuts, pressure from third parties to increase physicians' workload, and the turbulence of the policy environment-as important barriers to improving doctor-manager relationships. Other common sources of strain were concerns over resource availability and the relative power of doctors and managers. Sources of relationship tension particular to each country were also found. Substantial divergence of opinion was expressed with respect to internal factors that affect doctor-manager relationships. Respondents from the United States were more negative than those from the United Kingdom in their ratings of teamwork and communication between doctors and managers, and they were also less likely to have confidence in the medical staff. Respondents from the United Kingdom were more likely to believe that hospital management is driven more by financial than clinical priorities. Managers can implement several strategies to improve doctor-manager relationships, including greater organizational transparency in decision making; more frequent communication between managers and doctors; and more physician involvement in decision making, especially with regard to important resource-related decisions, and in organizational governance.     

How do health care professionals respond to advice on adverse side effects of contraceptive methods? The case of Depo Provera

CONTEXT: Depomedroxyprogesterone acetate (DMPA) (Depo Provera) is a long-acting contraceptive popular in the United Kingdom, particularly among young women. In the United States, use of DMPA has been instrumental in reducing teenage pregnancy rates. Evidence for a detrimental effect of DMPA on bone mineral density led to advice from drug regulatory authorities in the United Kingdom and the United States, recommending caution in prescribing DMPA, particularly for young people. OBJECTIVE: The study was conducted to explore changes in practice in response to prescribing advice about DMPA among primary care doctors and nurses working in the UK. METHODS: A self-completed questionnaire sent to 420 primary care health professionals. RESULTS: In response to the advice, 16% of practitioners would deter all women, and one third would deter young women, from using DMPA.One in five practitioners would limit use of DMPA to 2 years. Fewer than one in 10 would suggest contraceptive implants as an alternative contraceptive. CONCLUSIONS: The response of primary care professionals in their prescribing advice about DMPA risks increasing rates of unintended pregnancy in the UK, particularly among teenagers. The findings demonstrate an urgent need for a clear, balanced approach to advising health professionals on how to respond to new findings about adverse effects of contraceptives.     

Engaging nurses in smoking cessation: Challenges and opportunities in Turkey

This paper discusses the training of nurses in smoking cessation as part of routine patient care in Turkey. Formative research was carried out prior to training to identify challenges faced by smokers when trying to quit. Site visits to government hospitals and cessation clinics were conducted to observe health care provider-patient interactions involving behavior change.Four culturally sensitive cessation training workshops for nurses (n = 54) were conducted in Istanbul. Following training, nurses were debriefed on their experiences delivering cessation advice. Challenges to cessation counseling included lack of time and incentives for nurse involvement; lack of skills to deliver information about the harm of smoking and benefits of quitting; the medicalization of cessation through the use of pharmaceuticals; and hospital policy which devalues time spent on cessation activities. The pay-for-performance model currently adopted in hospitals has de-incentivized doctor participation in cessation clinics.Nurses play an important role in smoking cessation in many countries. In Turkey, hospital policy will require change so that cessation counseling can become a routine part of nursing practice, incentives for providing cessation are put in place, and task sharing between nurses and doctors is clarified. Nurses and doctors need to receive training in both the systemic harms of smoking and cessation counseling skills. Opportunities, challenges and lessons learned are highlighted.     

International Recruitment of Nurses: Policy and Practice in the United Kingdom

Objective. To synthesize information about nurse migration into and out of the United Kingdom in the period to 2005, and to assess policy implications.
Principal Findings. There has been rapid growth in inflow of nurses to the United Kingdom from other countries. In recent years, 40–50 percent of new nurse registrants in the United Kingdom have come from other countries, principally the Philippines, Australia, India, and South Africa. Outflow has been at a lower level, mainly to other English-speaking developed countries—Australia, the United States, New Zealand, Ireland, and Canada. The United Kingdom is a net importer of nurses. The principal policy instrument in the United Kingdom, the Code of Practice on International Recruitment, has not ended the inflow of nurses to the United Kingdom from sub-Saharan Africa.
Conclusions. Given the increasing globalization of labor markets, it is likely that the historically high levels of inflow of internationally recruited nurses to the United Kingdom will continue over the next few years; however the "peak" number reached in 2002/2003 may not be repeated, particularly as large-scale active international recruitment has now been ended, for the short term at least. New English language tests and other revised requirements for international applicants being introduced by the Nurses and Midwives Council from September 2005 may restrict successful applications from some countries and will also probably add to the "bottleneck" of international nurse applicants. Demographic-driven demand for health care, combined with a potential reduction in supply of U.K. nurses as many more reach potential retirement age means that international recruitment is likely to remain on the policy agenda in the longer term, even with further growth in the number of home-based nurses being trained.     

Pay for performance in hospitals: implications for nurses and nursing care

As pay-for-performance programs gain momentum, hospital administrators and clinical leaders will need to consider the organization's infrastructure and measures that promote quality management initiatives. Many hospital performance measures by the Centers for Medicare & Medicaid Services involve chronic diseases that may be best managed by an interdisciplinary team-based approach, of which nurses are significant members. While the primary focus of pay-for-performance has been concentrated on physicians, comparatively less attention has been given to the potential impact on nurses and nursing care. Moreover, the impact of the pay-for-performance measures on nursing labor and processes has not been well studied. Within acute care settings, increasing attention has focused on the structure of nursing, such as number and skill mix of nursing personnel, processes of care, and influence on patient outcomes. As pay-for-performance standards evolve and encompass patient outcomes, attention to nursing's contribution will follow. Nursing leadership will need to address a number of strategies to (a) address the impact of pay-for-performance on nursing performance measures as well as (b) on staff nurses' ability to contribute to the organization's efforts in achieving pay-for-performance standards, including education, documentation, team collaboration, and patterns of care.     

The organisation and development of primary care pharmacy in the United Kingdom

Primary care pharmacists carry out clinical and administrative work directly for family doctors and primary care organisations. They are a relatively recent innovation and their role in the United Kingdom (UK)'s National Health Service (NHS) is still developing. The economic liberalization of the NHS in the 1990s seems to have provided a major stimulus for the growth of primary care pharmacy. The establishment of the new professional group was not linked to a deliberate plan or change in health policy with respect to pharmacist development. Primary care pharmacy practice is much more varied and flexible than traditional pharmacy practice in the community and hospitals. Standards and professional organisation for primary care pharmacy are slowly emerging. Modernization of the NHS is providing many new opportunities, which primary care pharmacists are well placed to take advantage of. Traditional community pharmacy faces many problems unless it can learn to develop alongside primacy care pharmacy. Pharmaceutical care is set to improve in the United Kingdom, but the precise nature of future services and providers remains uncertain.     

Peer Reviewed: Paying for Performance in Population Health: Lessons From Health Care Settings

The appeal of pay-for-performance in health care derives from the conceptual view that paying doctors and hospitals more to deliver better care will encourage them to deliver better care. What lessons can be learned from the successes and failures of pay-for-performance in health care settings that apply to pay-for-performance in population health? We argue that pay-for-performance requires conditions that are not easily met in population health settings. Pay-for-performance has focused on narrow clinical problems whose success depends on identifiable actors with the motivation and resources to change clinical processes or outcomes. In contrast, population health has broad goals, many antecedents, and no single, identifiable fiduciary (a person who holds assets in trust for a beneficiary). Nevertheless, with careful attention, conditions for successful pay-for-performance in population health might be met.