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Financial Incentives increases physicians’ perception of burden and affects consumer satisfaction.
- Joan Gené-Badia, Pedro Gallo (2 July 2007)
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What about the impact of GP financial incentives on patient health?
- Mark Strong, John Radford, DPH (4 July 2007)
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Re: What about the impact of GP financial incentives on patient health?
- L S Lewis (5 July 2007)
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Financial incentives for practices - and equity for patients
- Caroline Mawer, Giuseppe Esposito, General Practitioner (24 July 2007)
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Joan Gené-Badia, Family Physician CAPSE - Barcelona University. 08036 Barcelona. SPAIN, Pedro Gallo
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The impact of financial incentives on the professional’s internal motivation found by Mc Donald et al.1 in his ethnographic case study of two English general practices is similar to what we found in a large sample of 257 Catalan primary care teams2. Certainly, financial incentives to meet clinical and organisational quality targets are becoming a common procedure in primary care despite the limited evidence on its effects on professionals and patients3. For this reason it is of utmost importance to pool international experiences and knowledge that might help to improve such initiatives. In this respect, common findings expand the external validity of McDonald’s et al. research and, particularly, our study completes and adds to of their results. The largest primary health care provider in Catalonia implemented in 2003 a twofold initiative based on a) a new financial incentive scheme based on quality of care targets for physicians, and b) a professional development scheme for both physicians and nurses. We had the opportunity to assess its impact on the quality of professional life of both physicians and nurses and on end-user satisfaction by means of a before and after study. Similarly to Mc Donald’s results, intrinsic motivation did not seem to change, although, we observed variations in other dimensions of quality of professional life. Clearly, as a result of the financial incentives, physicians perceived an increase in the dimension “demands made upon them”, differently from the nurses group which in our experience were not eligible and did not benefit from the financial scheme. We also found, as British nurses feared, that financial incentive schemes affect doctor-patient relationship. In addition, our case study reports that financial incentives scheme increases both physicians and nurses “perception of support from the management structure”. Despite overall user satisfaction did not vary significantly following financial incentives implementation, a negative relationship was found between general practitioners perception of the increase in demands made upon them and end-user satisfaction. That is, evidence points to financial incentives related to quality of care targets may increase physicians’ perception of burden as well as perception of support from upper management, and may have a negative impact on consumer satisfaction. Finally, it is worth noting that there is a great risk resulting from setting unrealistic targets to be met by doctors and nurses. Not bearing that in mind would lead to a greater perceived burden on professionals ultimately affecting user satisfaction and quality of the clinical-care provided. Bibliography 1. McDonald R, Harrison S, Checkland K, Campbell SM, Roland. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. BMJ 2007;334:1357-9 2. Gené-Badia J, Escaramis-Babiano G, Sans-Corrales M, Sampietro- Colom L, Aguado-Menguy F, Cabezas-Peña C, Gallo-Puelles P. Impact of economic incentives on quality of professional life and on end-user satisfaction in primary care. Health Policy, 2007;80:2-10 3. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early Experience with pay-for-performance. From concept to practice. JAMA 2005;294:1788-1793 Competing interests: None declared |
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Mark Strong, Clincal Lecturer Rotherham Primary Care Trust, Oak House, Rotherham, S66 1YY, John Radford, DPH
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McDonald et al’s report of GPs’ and nurses’ views of the Quality and Outcomes Framework (QOF) highlights the “box ticking” nature of this pay- for-performance contract.[1] Recording activity on an electronic template in order to generate payment may or may not reflect an intervention that benefits health. We have therefore proposed that incentives are linked more directly to positive health outcomes. GP practices are incentivised through the QOF to record the smoking status of their patients who have a chronic disease. A further incentive is paid for offering those patients identified as smokers either cessation advice or referral to a smoking cessation service. Rotherham practices achieved highly on the smoking related QOF indicators in both 2005 and 2006, costing the Primary Care Trust (PCT), which has a population of 250,000, approximately £276,000 in 2005 and £500,000 in 2006. Despite this the smoking prevalence amongst those on the Rotherham’s QOF chronic disease registers remained essentially unchanged. Given that smoking is the biggest single risk factor for coronary heart disease and many cancers, and is also the main risk factor for the progression of COPD, we in public health have asked ourselves: did we get value, in terms of health benefit, for our money? As a result of our deliberations we have proposed to the PCT Executive and the Local Medical Committee that the QOF contract be renegotiated. We suggested the following alteration to the smoking related indicators: firstly, the four-week quit target set for us as a PCT is allocated proportionally between practices; then, at year end, practices are rewarded a proportion of the 68 QOF points allocated for the current smoking indicators according to the number of quitters relative to their target. Unfortunately it is only possible to alter the QOF contract locally for PMS practices; national renegotiation would be required to alter the GMS QOF. This is difficult territory, moving away from tick-box activity based incentives towards outcome based incentives could appear to be penalising GPs for their patients’ unhealthy behaviours. However, as a PCT we are responsible for the health of our population, and we believe that this is a sentiment shared by our GPs. We are held accountable as a PCT through the quit target for decisions made by our population, an accountability it seems only fair to share. Committing NHS resources through a financial incentive scheme is only justifiable if quantifiable health benefits result. The current box ticking smoking indicators do not appear to deliver this benefit. We think this is worthy of wider discussion and debate. References 1. McDonald R, Harrison S, Checkland K, Campbell SM, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. BMJ 2007;334(7608):1357-9 Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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Mark seems to make a good case , as seen from a PCT/purchaser point of view. Fortunately, except in the case of PMS practices, it is not the prerogative of local agencies to change national GMS contracts. Unfortunately , it is the current practice of the NHS executive to recoup its £5ooM deficit by raiding the undefended budgets of General Practice. But what of value-for-money smoking cessation ? For years GPs were exhorted to advise people not to smoke , and many weak or anecdotal studies testified to the 'power' of doctor advice ! Then came more robust studies which showed a much more modest effect, if at all ( BMJ 2003;326:1175-1177 (31 May), doi:10.1136/bmj.326.7400.1175 ). Even the most powerful interventions only produce a 1-2 % overall maintained cessation at 1 year. NICE advice (http://guidance.nice.org.uk/page.aspx?o=429278 ) states "Although smoking prevalence has dropped sharply since the 1970s, this decline has been much less pronounced in the last decade. Current estimates suggest that it is dropping by 0.4% a year (Sproston and Primatesta 2004; West 2005)." Mark says that smoking prevalence is 'essentially unchanged' in Rotherham .. In my practice the prevalence has shown an apparent rise - due to ascertainment bias as a direct consequence of QOF. But closer examination shows a small and sustained effect on smoking cessation rates.. Even if only a small sustained effect ( 1-2% ) is evidenced for medical intervention... this would have a significant cost-saving. NICE guidance states "Smoking is estimated to cost the NHS £1.5 billion a year (Parrott et al. 1998). This estimate does not include other costs to government such as payment of sickness or invalidity benefits. Nor does it include the costs to industry or the individual smoker." Look again at your figures, Mark. If GPs are to do the work, they must surely be paid. Or we could legislate and tax the smokers out of public places. Competing interests: I am a GP dependent on QOF earnings to make up the deficit from NHS global sum cuts. |
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Caroline Mawer, General Practitioner London, Giuseppe Esposito, General Practitioner
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The report by McDonald et al on the effects of financial incentives on doctors and nurses used, as they acknowledge, a convenience sample of two practices. The Quality and Outcomes Framework (QOF) was however perhaps not primarily aimed at high-performing practices with established practice teams like the ones studied. As well as being a new way of remunerating doctors, it was also about equity for patients – about levelling up those practices that had not provided high levels of evidence -based care for all the important health topics. Working in an inner city practice recently taken over by the local PCT, currently staffed by locums, and with what might politely be described as a range of quality challenges; we are possibly the class of clinicians that QOF was most intended to influence. We have – after setting up safe systems in prescribing, handling of clinical correspondence and the other basics; and now we have some sort of handle on access – recently managed to turn our attention to long term conditions. The QOF has given us an invaluable framework to build on. We recognise we have a big quality hill to climb. For example, when we started, 12% of our known diabetics had an HbA1 of 10+ and an additional 25% had an HbA1 of either 9-10 or unknown. We know that chronic illness is underdiagnosed in the practice: 132 patients had abnormal blood glucose results that had not been adequately followed up. We have however used internal QOF reports both to find individual patients who are not getting evidence-based care, and also to allow us to prioritise our work by selecting topics that we feel are achievable within our current staff resources. Since financial gain means more resources to put into health gain, we have not felt any conflict in tackling areas that will get us relatively ‘easy’ points as well as those that are clinical priorities for our local population. With a current staff of locums, a backlog of health need and limited patient empowerment around self-management, we recognise that we will sometimes fall short – and are therefore aiming at 100% rather than the specified target levels. McDonald et al rightly suggest that organisational changes associated with QOF implementation have the potential to fundamentally change the way clinicians relate to each other. We would like to suggest that, in practices like ours, those changes may be very good indeed for patients. Competing interests: None declared |
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