Helen Lester presented on the role of pay for performance (P4P) in quality improvement in the UK. She discussed how P4P was introduced in the UK in 2004 to improve quality of care and address issues like variations in care. While P4P led to improved achievement on incentivized measures, it also resulted in unintended consequences like increased transaction costs, changes to roles of nurses and doctors, and less attention to non-incentivized areas. Studies on the impact of P4P on outcomes have shown mixed results. Overall, P4P has improved some aspects of care but its high costs, impacts on relationships, and narrow focus raise questions about its long-term role in quality improvement.

1. The role of P4P in quality
improvement
Helen Lester
University of Birmingham
October 26th 2011

2. What I‟m going to cover
• Where we‟ve come from
• Where we are now and why
• Where we‟re going…

3. Defining quality
Quality of care for individual patients
• Access - can patients access the heath care they need?
• Safe
• Effectiveness - is it effective when they get there?
• clinical or technical effectiveness
• effectiveness of interpersonal care
Additional domains of quality for populations
• Equity
• Efficiency
•  Leading to desired health outcomes

4. Background: Improving quality in the 1990s
Motive:
• Recognition of care variation by the medical profession
• Recognition of care variation by Government
Means:
• Development of methods of measuring quality
• Increasing computerisation of practices and electronic data
record
• Quality improvement initiatives:
 National Service Frameworks for major chronic diseases
 Audit
• Rise of evidence based medicine

5. Quality of care in the UK improved
between 1998 and 2003
90
Overall score (max 100)
85
80
Angina
75
Diabetes
70
Asthma
65
60
55
50
1997 1998 1999 2000 2001 2002 2003 2004
Campbell et al. BMJ 2005; 331: 1121-1123

6. Background: Improving quality in the
2000s
• “We want to be resourced and rewarded for providing
high quality care”
• In 2001, a BMA ballot found that 86% of GPs would
consider resigning if a new contract could not be secured
by the BMA
• Political will to invest in the NHS underpinned by
sustained economic growth

7. UK expenditure on health care since 1990

8. USA: P4P
• In a national survey in USA, 52% of HMOs (covering 81%
of enrollees) report using pay for performance (Rosenthal
2006)
• Average of 5 performance measures per scheme
• Rewards for reaching fixed threshold dominate; only 23%
reward improvement
• 5-7% of physician pay

9. Domains and points from April 2011
Domain No. of Indicators Pts % of
total
Clinical 87 661 66
Organisational 34 165.5 17
Patient Experience 1 33 3
Additional Services 9 44 4
QP 11 96.5 10
TOTAL 142 1000 100%

10. Achievement for 50 „stable‟ clinical indicators
Median reported
achievement:
2004/5 84.9%
2005/6 89.2%
2006/7 91.0%
2007/8 90.9%
2008/9 90.8%

11. Intended consequences
What might the effects be?
• Increased computerization
• Better organised care - more systematic protocol driven
care
• Greater job satisfaction
• Improved processes of care
• May be some improvements in outcomes?

12. Trends in job satisfaction
7
Mean overall satisfaction
6 5.23
4.67 4.62 5.24
5 4.26
3.95 4.6
4
3
2
1
1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Survey year

13. Estimated GP practice vacancies per 100,000
patients
2005 2006 2007 2008 2009 2010
England 3 month 2.6% 1.2% 0.9% 0.3% 0.3% 0.5%
GP vacancy rate

14. Improved care: data from QuIP 1998-2007
Campbell et al NEJM 2007; 357: 181-190 and 2009; 361: 368-378

15. Asthma
Step change in level (p<0.001)
Improvement post 2005 continued at pre-contract rate
(p=0.16)

16. Has P4P improved outcomes?
• Data on associations between process performance and
outcomes are mixed
• Work in press from Tim Doran based on QOF suggests that
in absolute terms, improvement in process performance
between 2004-8 resulted in improvement in intermediate
outcomes performance of
o 1.3% (BP)
o 2.0% (CVA)
o 2.2% (Diabetes)
o 3.6% (CHD)

17. Impact of P4P on hospital costs and mortality
• “The headline finding from this research is that there is an
association between achievement of QOF indicators and
some measurable reduction in costs for hospital care and
mortality outcomes. This association is stronger for some
QOF indicators than others and particularly strong for stroke
care.”
• A single point increase in QOF stroke scores across
England was associated with:
o 2,385 fewer deaths a year
o Reduction in secondary care costs of £22.15 million a year
(Health Foundation report: Do quality improvements in primary care reduce
secondary care costs? February 2011)

18. Unintended consequences
• Transaction costs
• Changes to practice nurse and salaried doctor roles
• Less holistic approach
• Less attention to non incentivised areas of care
• Equitable health intervention

19. Transaction costs
• Year 1 (04-05) £76 per point
£624,132,687
• Year 2 (05-06) £125 per point
£1,063,583,954
• Year 3 (06-07) £125 per point
£1,268,175,404

20. Overpaid NHS doctors and too few practitioners
'knocks three years off Britons' lives'
Britons would be far healthier if the NHS paid its doctors less but employed
more of them, a shock international report has concluded.
UK health spending is on a par with other prosperous countries - but its
people are less healthy because too much of the money goes towards GPs'
and consultants' pay packets.
At the same time, Britain has fewer doctors per head of population than most
countries in the Western World - and owns far less hi-tech equipment such as
cancer scanners because it cannot afford them.
Daily Mail 30th November 2010

21. What do patients think?
• 52 patients on QOF chronic disease registers in 15 practices
across England
• Interviewed at length Jan-March 2011
• Thought the status quo was great and high trust in their GPs
• No one had heard of QOF
• Almost all thought it strange to reward simple tasks
• What has happened to GPs‟ professionalism?

22. The value of money as a quality
improvement tool
• The majority thought paying for performance was an inappropriate
quality improvement tool:
“ Personally I think it’s wrong. I think they should deliver the quality of
care because it’s the professional thing to do.” (Male, 54, Hypertension)
“They shouldn’t get rewarded for it because it should be part of their
everyday job.” (Female, 59, CKD)
“ ...you would like to think they were doing it because they thought it
was necessary and a part of your care more than possibly, oh, well, if
we do him we get extra pay. I don’t like the idea of that.” (Male, 77,
Asthma)

23. Payment for simple tasks
• Most were surprised to hear the practice was paid
money for doing ‘simple things’ :
“Why should you be paid extra for something that is so simple that a
nurse could do it? That doesn’t make any sense.” (Male, 77, Asthma)
“I certainly didn't realise that you got an extra payment for taking
somebody's blood pressure, good heavens.” (Female, 65, Diabetes)
• Incentives should be in place for more complex tasks:
“I know some of them do minor surgery in there and I think they should
have rewards for doing the minor surgery because that saves the
hospital a lot of time...” (Female, 59, CKD)

24. Impact on care received
• No patient had heard of the QOF
• 75% had not noticed changes in their care:
“I don’t think it has changed at all because I’ve been on that
medication and I’ve always had a review, had my blood
pressure checked every six months.” (Female, 59, CKD)
“I haven’t noticed a difference... I don’t get any letters to
say...I’m due for a blood test or anything like that.” (Male, 87,
Epilepsy)

25. The importance of baselines: Effect of pay for
performance on blood pressure control and monitoring
Serumaga B et al. BMJ 2011;342:bmj.d108

26. Changes to nurses‟ roles
“They (the GPs) forget we’re actually nurses. You’ve not
stopped all day because you have had ill patients. And
then they come in and tell you that you are 1% down on
a target.” (practice nurse)
“All the three nurses, we agree that we’re doing a lot
more of their work for them (the doctors), and not much
in the way of money recognition.” (practice nurse)
McDonald, Lester and Campbell, Soc Sci Med 2009; 68(7);1206-1212

27. Changes to salaried doctor roles
“ “They are feathering their own nests essentially and I do
think that it, the other aspect of it is I think they are abusing
the younger generation of doctors.” (salaried GP)
Lester et al. British Journal of General Practice 2009;59:908-915

28. Less holistic approach?
“The profession has essentially been bribed to
implement a population based disease management
program that often conflicts with the individual patient
centered ethos of general practice…it comes
dangerously close to medicine by numbers and
threatens the basis of general practice.”
Lipman T. Br J Gen Pract 2005; 55: 396.

29. Unintended consequences in GP behaviour
• 57 family-practice professionals were interviewed in 24
representative practices across England
• Four particular types of unintended consequences were
identified:
o measure fixation
o tunnel vision
o misinterpretation
o potential gaming
Lester, Hannon and Campbell. BMJ Qual Saf doi:10.1136/bmjqs.2010.048371

30. What happens to non incentivised areas?
• Longitudinal analysis of achievement rates for 42 activities
(23 included in incentive scheme, 19 not included)
• 148 general practices in England (653 500 patients)
• There was no overall effect on the rate of improvement for
non-incentivised indicators in the first year of the scheme,
but by 2006-7 achievement rates were significantly below
those predicted by pre-incentive trends
• Improvements associated with financial incentives seem to
have been achieved at the expense of small detrimental
effects on aspects of care that were not incentivised
Doran et al. BMJ 2011; 342:d3590 doi: 10.1136/bmj.d3590

31. Exception reporting by area deprivation
quintile
100
80
Quintile 1
Quintile 2
Overall mean exception rate
Quintile 3
Quintile 4
Quintile 5
60
40
20
0
05/06 06/07
QOF year

32. Inequality in quality of care
Achievement by area deprivation quintile
100
80
Overall reported achievement
60
40
Quintile 1
20
Quintile 2
Quintile 3
Quintile 4
Quintile 5
0
04/05 05/06 06/07
QOF year
Doran et al. Lancet 2008; 372: 728-736.

33. What happens when you retire indicators?

34. Keeping plates spinning
• Expectation that work in removed areas will continue since
„embedded‟ in primary care
• GPs in the UK consistently say that this will not be the case
• No UK evidence base to help us answer this question

35. Kaiser Permanente Northern California Data
• Longitudinal analysis
• 35 medical facilities of Kaiser Permanente Northern
California, 1997-2007
• 2 523 659 adult members of KP
• Four „shared‟ indicators
 yearly assessment of patient level glycaemic control (HbA1c
<8%)
 screening for diabetic retinopathy
 control of hypertension (systolic blood pressure <140 mm
Hg)
 screening for cervical cancer

36. Hypertension Control (systolic<140), ages 20
and up
100
80
% in conrol
60
40
20
0
2002 2003 2004 2005 2006 2007
year
Red dot: incentive off, Green dot: incentive on
Lester et al BMJ 2010;340:c1898

37. Diabetes Glycaemic Control (<8%)
ages 18-75
80
60
% in control
40
20
0
1999 2000 2001 2002 2003 2004 2005 2006 2007
year
Red dot: incentive off, Green dot: incentive on

38. Diabetic Retinopathy Screening, ages 31 and up
100
% screened
80
60
1999 2000 2001 2002 2003 2004 2005 2006 2007
year
Red dot: incentive off, Green dot: incentive on

39. Cervical Cancer ages 21-64
80
% screened
60
1999 2000 2001 2002 2003 2004 2005 2006 2007
year
Red dot: incentive off, Green dot: incentive on

40. 2011 Cochrane reviews
• Flodgren at al An overview of reviews evaluating the effectiveness of
financial incentives in changing healthcare professional behaviours and
patient outcomes DOI: 10.1002/14651858.CD009255
• “Financial incentives may be effective in changing healthcare
professional practice. The evidence has serious methodological
limitations and is also very limited in its completeness and
generalisability”.
• Scott et al. The effect of financial incentives on the quality of health care
provided by primary care physicians DOI:
10.1002/14651858.CD008451.pub2
• “There is insufficient evidence to support or not support the use of
financial incentives to improve the quality of primary health care.
Implementation should proceed with caution and incentive schemes
should be carefully designed and evaluated.”

41. State of play 2011- Yes P4P has a role
• Improved care in long term conditions
 Achievement for most incentivised activities increased
over the first 3 years, but little improvement in Year 4
• Reduced variations in quality of care
 The poorest performing practices improved the fastest
Overall inequalities in quality of care for incentivised
activities almost disappeared by Year 3
• Some staff are happier
 4,000 additional physicians recruited (15% increase)
 43% GPs are now salaried
 Income of GP principals increased by up to 25%

42. But…
• Too great a cost to the public purse
• Changes to the doctor patient relationship
• Loss of focus on other areas of care

43. If this was 2003...
• Know the baseline achievement
• Consult the public
• Pilot all indicators
• Attach less money to each measure
• Monitor what happens closely
• Set up some decent longitudinal research to inform the next
Cochrane review

44. Thank you very much for listening!
H.e.lester@bham.ac.uk