David Colin Thome


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David Colin Thome

  1. 1. Rapid History of GP Development and Incentives • 1948- registered list embedded into the inception of the NHS • 1966- new GP contract-incentives for teams to expand the role of the practice • 1990-new contract-specific monetary incentives to reward good practice • 1991-Fundholding • 2004-new GP contract with extensive P4P • New policies- • Next Stage Review 2008 • GP commissioning 2010
  2. 2. Primary Care facts • Most people’s contact with the NHS is through primary care: • Over 90% of all contact with the NHS takes place outside hospital – with the primary care staff who work in GP practices, pharmacies, dental surgeries and opticians and with the nurses, health visitors, allied health professionals and healthcare scientists working in our community health services. • 99% of the population is registered with a family doctor • GPs and nurses in general practice see over 800,000 people a day –The c.8,500 practices in England deliver 314m consultations each year (Healthcare Commission “State of the Nation” Report 2006). This represents an average 6 per year for each person or 720 weekly by each practice- 80% of all clinical consultations • There were 30,358 GPs in September 2003, and 33,091 in September 2006 ( England only) • The NHS invests around £8 billion in GP services each year, 9% of the overall NHS budget • GP prescribing in 2007/08 accounted for a further £8 billion of the NHS budget.
  3. 3. QOF
  4. 4. The following principles relating to the QOF were agreed by the negotiators of the new GMS contract: • Indicators should, where possible, be based on the best available evidence • The number of indicators for each clinical condition should be kept to the minimum number compatible with an accurate assessment of care • Data should not be collected purely for audit purposes • Only data useful in patient care should be collected • Data should not be collected twice.
  5. 5. 2004 • The QOF contains 136 indicators in four domains: clinical, organisational, patient experience and additional services (additional services are clinical services that not all practices provide, such as maternity services). • Each domain contains indicators that define the specific process or outcome that practices should achieve for their patients, based on best available evidence. • Achievement of clinical indicators is measured automatically by extracting data from GP clinical systems. • Practices state whether or not they have achieved other indicators through a web-based server and PCTs can require written evidence for these. • Achievement of indicators is rewarded through payments. QOF is worth just over £1 billion in England.
  6. 6. The 2006/07 QOF • nineteen clinical indicator groups: coronary heart disease, heart failure (formerly left ventricular dysfunction), stroke (including transient ischaemic attacks), hypertension, diabetes, chronic obstructive pulmonary disease, epilepsy, hypothyroidism, cancer, palliative care, mental health, asthma, dementia, depression, chronic kidney disease, atrial fibrillation, obesity, learning disabilities and smoking.
  7. 7. New QOF areas 09-10 • cardiovascular risk assessment for patients with hypertension (as part of the wider programme of vascular checks being rolled out from next year) • sexual health: better advice on contraception • depression: a new indicator based on assessment of severity • improvement to chronic kidney disease indicators • improvement to diabetes indicators • improvement to chronic obstructive pulmonary disease indicators • transferring into QOF what is currently a Directed Enhanced Service (DES) for improving treatment of heart failure
  8. 8. QOF • The QOF was the first example of its kind in the world, introducing a dramatically more systematic focus on evidence-based care. It has a number of strengths: – Although voluntary there is almost universal participation covering 99.7% of the registered population of England. – According to the 2009 Commonwealth Fund Survey of GPs, the UK continues to be a world leader in quality systems. – Achievement of QOF indicators can save lives and reduce emergency admissions to hospital.[1] – There is evidence that quality improvement initially accelerated when QOF was introduced. – The gap between quality of care in deprived and affluent areas has narrowed. • [1] Research shows achievement of QOF targets could save 451 lives per 100,000 people per year (in total, not the increase compared to baseline before QOF).
  9. 9. The Quality and Outcomes Framework was the first example of its kind in the world, introducing a dramatically more systematic focus on evidence-based care. 100 95 79 75 72 58 50 43 41 30 25 0 AUS CAN GER NETH NZ UK US Percent receive AUS CAN GER NETH NZ UK US financial incentive: Achieving certain 33 10 9 6 43 92 23 clinical care targets GPs are ahead of family doctors in High ratings for patient satisfaction 5 — 5 1 2 52 20 comparator countries in uptake of Managing patients with chronic disease/ 62 37 24 47 68 79 8 financial incentives for quality, IT use complex needs Enhanced preventive 53 13 28 18 42 72 12 care activities and chronic disease management Participating in quality improvement 35 7 21 28 47 82 19 activities Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
  10. 10. Research indicates that there is some under-reporting of prevalence in QOF registers as compared to expected prevalence, and this may be more pronounced in deprived urban areas Coronary Heart Disease – QOF – CHD06. Blood Pressure of 150/90 or less – As a percentage of Estimated CHD Prevalence (1) – 2007/8 By SHA Org Le ve l S HA PCT Code (All) Pra ctice C ode (A ll) Yea r 200 7/8 Sp ea rhea d (All) PC T Sh ort (All) 10 0% BP Not Measured 9 0% & not on CHD Register 8 0% - as a % of estimated CHD Prevalence 7 0% BP Not Measured Dabut on CHD Register ta 6 0% - asNo t% eg estimated Est a R of N ot Con t 5 0% ReCHDt Prevalence red g bu B P Not Me asu BP Measured BP > 1 50/ 90 4 0% % of the estimated people with CHD BP 1 O ver 150/90 50 /9 0 or less - as a % of estimated 3 0% who are at increased risk because CHD Prevalence BP is not 150/90 or less 2 0% BP Measured 1 0% England 150/90 or less - as a % of estimated 0% CHD Prevalence England South Central London North East South East East Midlands West Midlands Yor kshire & East Of England North West South West Humber Coast (1) M odelled estimates of prevalen ce o f CHD fo r PCTs in England Version 1.0 (Eastern R egion Pu blic H ealth Ob servatory, September 2008) S HA These estimates of the prev alence of CHD in people aged 16+ have been cal culated using a m odel devel oped at the Dept of Primary Care and Social Medicine, Im peri al College, London. The m odel was dev eloped usi ng data from the 2003-2004 Health Surv eys for England. The m odel takes i nto account age, sex, ethnicity, sm oking status and depriv ation score.
  11. 11. Prevalence rewards improved
  12. 12. However, there have been criticisms of early QOF that its clinical indicator set didn’t correlate well with possible population health gains • QOF indicators are not optimally aligned with interventions and activities that will have the maximum impact on population health • Cookson et al* correlated evidence on the population health gains from cardiac prescribing interventions with the relevant QOF payments • Plotted points associated with these interventions against likely lives saved p.a. per 100,000, with a relatively poor fit. Source: Fleetcroft, R. and Cookson,, R. (2005) Do the incentive payments in the new NHS contract for primary care reflect likely likely population health gains? Journal of Health Care Research and Policy Policy
  13. 13. The incentives in the Quality and Outcomes Framework for evidence based quality care are predominantly focused on diagnosis, management and secondary prevention of long term conditions. Some primary prevention activity clearly takes place in GP Everyday practices, but there is no systematic framework for ensuring activity that people who need it have access to it or for measuring quality. Only 7.5% of the QOF is dedicated to health promotion/illness prevention, covering: Prevention • registers for obesity and learning disability points • recording blood pressure and smoking status • having a stop smoking strategy. • for 2009/10: CVD primary prevention and sexual health QOF 2009/10 Mostly Primary prevention disease Disease management manageme nt Organisational Patient Experience 14
  14. 14. Proposed scope and frequency of review ‘flu indicators Advice from JCVI Indicators out of scope Indicators within scope Organisational indicators RCGP practice accreditation Disease management and secondary prevention (excluding flu indicators) Patient experience indicators GP patient survey Frequency of output for indicators Primary prevention and managed by NICE: health inequalities •to review all 88 indicators in 3-4 years (20-30 per year) •cost effectiveness evidence for an additional 10 indicators per year
  15. 15. Effect of patient and practice characteristics on exception reporting rates-Roland 08 • We estimate that exception reporting increased practice income by an average of £1,738 ($3,476), and individual physicians’ income by about £500 ($1,000), which is less than 0.5 percent of average family practitioner net income. • The total cost to the Department of Health in England was approximately £17.2m ($34.4m) in 2005-06. Given that the overall cost of the pay-for-performance scheme in that year was approximately £1.15 billion ($2.3 billion), exception reporting accounted for 1.5 percent of the cost of the scheme.
  16. 16. There is also little difference between average exception rates in practices serving the most and least deprived populations •GPs in deprived areas achieved high scores without high rates of exception reporting, and the differences in scores between affluent and deprived areas are small and of relatively little clinical significance. •Practices serving the most deprived populations had an exception rate that was 0.67% higher than practices serving the least deprived populations in 2006/07. Source: Doran Tet al; Effect of financial incentives on inequalities in the delivery of primary medical care in England: analysis of clinical activity indicators for the QOF, The Lancet 2008; Vol 372
  17. 17. But there is gaming of exception reporting which does not appear to be associated with practice population characteristics. The patients being excepted may be the harder to reach 10 exception rates for group 2a practice. CHD patients within 80 Increases in year 4 year 3 reported year 2 achievement between years two and three of 60 the QOF for practices between the old and new Frequency maximum 40 thresholds were associated with concurrent increases in exception rates, 20 some of which might have been inappropriate - for example by excluding difficult 0 patients. 0 20 40 60 80 100 Percentage exception rates Source: Doran Tet al; Effect of financial incentives on inequalities in the delivery of primary medical care in England: analysis of clinical activity indicators for the QOF, The Lancet 2008; Vol 372. Diagram is from unpublished slides – not for publication
  18. 18. QOF • But QOF has a number of serious weaknesses in its current form: – Average achievement has been over 90% since QOF began in 2004 and has settled at around 95%. QOF is no longer challenging and does not discriminate well between different levels of quality. – The current indicators and payment levels are not aligned optimally with interventions that have greatest potential to improve health. – The rate of quality improvement started slowing in 2005 and appears to have reached a plateau.[2] – QOF represents a high proportion of practice income at 16% (£1.1b). – Primary Care Trusts (PCTs) do not have any flexibility to focus the incentives on local health priorities • [2] Research awaiting publication shows that QOF only saved an additional 11 lives per 100,000 people per year when introduced (lower that the maximum potential increase of 56 per 100,000 if all eligible patients received the interventions). Reforms in 2006 led to no increase at all because the baseline performance of the average practice had already exceeded the target performance for full payment.
  19. 19. • Contract negotiations for years 2011-2012