1. Doran Paying Physicians for Quality Primary Care Reform in the UK Tim Doran National Primary Care Research and Development Centre University of Manchester Québec Medical Association, April 2010 NPCRDC Paying Physicians for Quality

2. Doran Primary Care in the UK NPCRDC Paying Physicians for Quality

3. Structure of the National Health Service 8,500 / 1,600 152 10 Department of Health Strategic Health Authorities Primary Care Trusts General Practices Hospitals Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms NPCRDC Paying Physicians for Quality

4. New Labour TM Quality of care, 1997 to 2001 Modernisation Agency NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

5. NHS Spending “... health spending will increase by about 5% annually for five years...” “You’ve stolen my bloody budget!” NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

6. Doran The Quality and Outcomes Framework NPCRDC Paying Physicians for Quality

8. The Quality and Outcomes Framework (QOF) The original framework o Introduced April 2004 for all general practices in the UK o 146 quality indicators covering: secondary prevention for 10 chronic conditions organisation of care patient experience additional services o Each indicator allocated between 0.5 and 56 points (1,050 in total) o Achievement scores are publicly reported www.qof.ic.nhs.uk NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

9. The quality indicators Clinical indicators Disease areaIndicatorsPoints asthma772 cancer212 chronic obstructive pulmonary disease845 coronary heart disease15121 diabetes1899 epilepsy416 hypertension5105 hypothyroidism28 mental health541 stroke1031 total76550 Disease areaIndicatorsPoints asthma772 cancer212 chronic obstructive pulmonary disease845 coronary heart disease15121 diabetes1899 epilepsy416 hypertension5105 hypothyroidism28 mental health541 stroke1031 total76550 NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

10. The quality indicators Organisational indicators ActivityIndicatorsPoints Organisation of care56184 record keeping1985 patient communication88 education and training929 practice management1020 medicines management1042 Patient experience4100 Additional services1036 Access---50 Overall quality---30 Holistic care---100 total70500 NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

11. Achievement thresholds CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg Minimum threshold Maximum threshold Points: 0 to 19 points Income: £0 to £1,444 (C$0 to C$2,240) NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

12. “…fragmentation and privatisation of primary care…” “…the fingerprints of the World Trade Organisation and the huge financial muscle of the medical industrial complex …” ‘COERCION OF PATIENTS’ “…hazardous interactions and iatrogenic illness…” “…threatens the very survival of the NHS.” “…losing our professional identity and reputation.” “…deeply corrosive to the ethical practice of medicine.” “…loss of critical thinking.” ‘DE-PROFESSIONALIZATION’ ‘LOSS OF CORE VALUES’

13. The Quality and Outcomes Framework (QOF) Remunerating practices o Each point scored earns an average practice £76 (C$118) o Remuneration adjusted for disease prevalence and list size o Maximum of £79,800 (C$124,000) per practice £25,000 (C$39,000) per physician o Payment increased to £125 (C$194) per point in Year 2 o No restriction on how remuneration is distributed NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

14. coronary heart disease register – 100 patients blood pressure controlled Achievement = 50/100 = 50% = 10.6 points = £800 (C$1,240) 50 Exception reporting CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

15. coronary heart disease register – 100 patients blood pressure controlled Achievement = 50/90 = 56% = 13.1 points = £995 (C$1,540) 50 40 Exception reporting CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg 10 exception reported NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

16. coronary heart disease register – 100 patients blood pressure controlled Achievement = 50/70 = 71% = 19 points = £1,444 (C$2,240) 50 20 Exception reporting CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg 10 exception reported 20 inappropriately exception reported NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Framework Thresholds and payment Exception reporting

17. Doran Results of the Framework NPCRDC Paying Physicians for Quality

18. NHS Information Centre (www.qof.ic.nhs.uk) Year% of total points scored Mean earnings per physician 2004-0591.3%C$ 35,260 2005-0696.3%C$ 61,210 2006-0795.5%C$ 57,815 2007-0896.8%C$ 58,590 Results for Years 1-4 Points scored and remuneration Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

19. Achievement of incentivised indicators Achievement rate NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

20. Achievement of incentivised indicators Achievement rate NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

21. Uplift in achievement Incentivized and unicentivized indicators Uplift in achievement 2004/52006/7 NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

22. Inequality in quality of care Achievement by area deprivation quintile Doran et al. Lancet 2008; 372: 728-736. 2004-052005-062006-07 Reported achievement Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms Paying Physicians for Quality

23. Incentivised process AST7: Asthmatics immunised against influenza in previous season Achievement rate NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

24. “I actually think it's a good idea… it makes things tangible and quantifies things… …although I hate it.” McDonald et al BMJ 2007;334:1357

25. Doran Summary NPCRDC Paying Physicians for Quality

26. o Quality of care Achievement increased in Years 1-3 Significant improvement over projected rates (up to 38% in Year 1) Achievement plateaud from Year 2 onwards o Inequality of care Poorest performing practices improved the most Inequalities almost disappeared by Year 3 NPCRDC Paying Physicians for Quality Summary Quality of care for incentivized indicators Summary

27. o Quality of care – unincentivized indicators Little effect on achievement in Year 1 Borderline underachievement by Year 3  up to 10% below projected rates o Inequality of care ??? NPCRDC Paying Physicians for Quality Summary Quality of care for partially incentivized and unincentivized indicators Summary

28. Conclusions Lessons from the UK’s experiment with pay-for-performance NPCRDC Paying Physicians for Quality Create the necessary infrastructure Regularly review all elements of the scheme Pilot indicators and model allocation formulae Base indicators on important outcomes if possible Involve physicians and patient groups from an early stage Establish baseline performance Monitor effects on professional behaviour and morale

29. Effect of increasing payment thresholds Treatment: treated with beta blocker Percentage achievement Number of practices Maximum threshold NPCRDC Paying Physicians for Quality Primary Care in the NHS The Quality and Outcomes Framework Effects of the Reforms

30. Further information: tim.doran@manchester.ac.uk