Intended for healthcare professionals


Fairness of financial penalties to improve control of Clostridium difficile

BMJ 2008; 337 doi: (Published 21 November 2008) Cite this as: BMJ 2008;337:a2097
  1. A Sarah Walker, statistician12,
  2. David Spiegelhalter, professor of the public understanding of risk34,
  3. Derrick W Crook, consultant microbiologist1,
  4. David Wyllie, research fellow5,
  5. James Morris, consultant pathologist1,
  6. Tim E A Peto, professor of infectious diseases1
  1. 1National Institute for Health Research Oxford Biomedical Research Centre Programme, John Radcliffe Hospital, Oxford OX3 9DU
  2. 2MRC Clinical Trials Unit, London NW1 2DA
  3. 3MRC Biostatistics Unit, Institute of Public Health, Cambridge CB2 0SR
  4. 4Statistical Laboratory, Centre for Mathematical Sciences, Cambridge CB3 0WB
  5. 5Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, OX3 9DU
  1. Correspondence to: A S Walker asw{at}
  • Accepted 15 September 2008

Trusts in England have been given targets to reduce C difficile infection rates. But Sarah Walker and colleagues argue that the way they are calculated makes financial penalties almost impossible to avoid

Financial incentives are increasingly being used to promote delivery of efficient, high quality health care.1 2 3 However, it is widely agreed that such incentives have to be carefully constructed, with clear and simple links between behaviours or outcomes and incentives, direct indicators that validly measure the desired behaviours or outcomes, and sufficient stability to give surety to hospitals that effort (time, money) put into achieving targets is warranted.1 3 We examine how well these criteria are met by the financial penalties introduced for failing to reduce hospital acquired Clostridium difficile infection as part of the 2008-9 standard National Health Service contract for acute services.

What are the targets and financial penalties?

In response to a new hypervirulent strain of C difficile causing large hospital outbreaks since 2003,4 5 the Department of Health recently set a target of a 30% reduction in C difficile infections in patients aged 2 years or older across the entire health economy (within and outside acute NHS trusts) from 2007-8 to 2010-11.6 All financial penalties relating to this target are based on comparing the number of cases observed in the current “contract year” to the number of cases observed in the previous “baseline” financial year. If 200 or more cases are observed in the baseline or contract year, the penalty is based on failing to meet the target reduction in the contract year (0.2% of total contract year revenue for every percentage point the target is underachieved, capped at 2% when target underachieved by 10%). However, if fewer than 200 cases are observed in the baseline and contract year, the penalty is based on exceeding the …

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