The introduction of financial incentives for general practices in England has helped reduce inequalities in service delivery between affluent and poor areas in the areas in which the scheme was trialled. This is the conclusion of authors of an Article published early Online and in an upcoming edition of The Lancet.
In 2003, the UK Government renegotiated the national contract with general practitioners, and introduced the quality and outcomes framework — a financial incentive scheme that pays general practices in the UK for their performance against a set of quality indicators. In the first full year of the scheme, most practices reported high levels of achievement for the clinical indicators. And levels of achievement have, on average, increased most years for most indicators. However, concerns have been raised that general practices in poorer areas serving deprived populations might have achieved lower levels of performance and received less generous financial rewards — thereby widening the inequality gap. Dr Tim Doran, National Primary Care Research and Development Centre, University of Manchester, UK, and colleagues investigated the relationship between socioeconomic inequalities and delivered quality of clinical care in the first three years of the scheme, ie 2004-5 to 2006-7.
Practices involved were divided into five equal groups based on the level of deprivation of the area they served. The study looked at 48 clinical indicators which had remained largely unchanged during the three years, covering care for conditions including heart disease, diabetes, epilepsy, asthma, high blood pressure, mental health and stroke. Each practice was awarded points on a sliding scale based on the proportions of patients achieving the targets. In year 1 (2004-5), GBP £76 (adjusted for practice size and disease prevalence) was awarded for each point, which increased to GP £126 in years 2 and 3. A total of 1050 points was on offer in Years 1 and 2, and 1000 points in Year 3.
The median overall reported percentage of patients achieving the targets was 85.1% in year 1, 89.3% in year 2, and 90.8% in year 3. In year 1, the most deprived areas had a median achievement of 82.8% compared with 86.8% in the most affluent areas. However by year 3, the most deprived areas had improved substantially to record a median achievement of 90.8%, compared with 91.2% in the most affluent area – narrowing the gap in achievement from 4.0% to 0.8% over the three years. Furthermore, the worse a practice had performed in the past, the greater its improvement in achievement during the study period. An 'average' practice (i.e. one scoring an average number of points, with an average population size and average prevalence of each of the conditions) would have earned bonuses of over £70,000 in Year 1, and over £120,000 in Years 2 and 3 as a result of their performance under the framework. The practice partners could distribute this money on services, infrastructure and salaries in whichever manner they chose.
The authors conclude: "Our study has shown that variation in the quality of care related to deprivation was reduced during the first three years of the financial incentive scheme…More than 60% of the gap in life expectancy between the fifth of areas with the greatest material deprivation and poorest health in England and the rest of the country is attributable to diseases targets in the incentive scheme, particularly coronary heart diseases, cancer, and chronic obstructive airways disease…Generation of more equitable provision of prevention and care for these disorders means that the use of financial incentives seems to have the potential to make a substantial contribution to the reduction of health inequalities."
In an accompanying Comment, Dr Barbara Starfield, Department of Health Policy and Management, School of Hygiene and Public Health, Bethesda, MD, USA, says: "We cannot afford to rest on our laurels with the Quality and Outcomes Framework or other similar schemes. They are expensive and we need to know if they reduce suffering and inequities in suffering. There are now many indicators that we can apply. With advances in concepts and techniques of assessment, we should be up to the task."
Dr Tim Doran, National Primary Care Research and Development Centre, University of Manchester, UK T) +44 (0)161 275 7664 E) tim.doran@manchester.ac.uk
Dr Barbara Starfield, Department of Health Policy and Management, School of Hygiene and Public Health, Baltimore, MD, USA contact by e-mail only E) bstarfie@jhsph.edu
For full paper please contact tony.kirby@lancet.com (UK,rest of world) or Martine Persico ( m.persico@elsevier.com ) (US and Canada)
The Lancet