1. Financial incentives Levers for change in general practice and primary care, Nuffield Trust 6 November 2014 Matt Sutton

2. Acknowledgements Draws on evidence from evaluations of several schemes: –The Quality and Outcomes Framework –Advancing Quality in the North West of England –Commissioning for Quality and Innovation (CQUIN) –Best Practice Tariffs –Non-Payment for Emergency Readmissions –Payment by Results for Drugs Recovery Pilot Programme With several co-authors Views expressed do not necessarily reflect those of the funders: the Department of Health, NIHR and the NHS

3. The evidence base There have been several formal reviews of the international evidence on financial incentives –Cochrane reviews in 2011 (e.g. Flodgren, Scott) found few studies of sufficiently rigorous quality, and mixed results –Reviews of wider literature show that context matters, as do specific aspects of design and implementation There is considerable experience with using financial incentives in England –Like the international evidence, it shows very mixed results

4. Main results The QOF led to sustained higher quality on the incentivised measures and lower emergency hospital admissions

5. Effect of the QOF on admissions

6. Main results The QOF led to sustained higher quality on the incentivised measures and lower emergency hospital admissions The AQ Programme in the North West initially led to a 6% relative reduction in mortality and was highly cost-effective

7. Long-term effect of AQ on mortality

8. Main results The QOF led to sustained higher quality on the incentivised measures and lower emergency hospital admissions The AQ Programme in the North West initially led to a 6% relative reduction in mortality and was highly cost-effective The £1bn CQUIN initiative led to no demonstrable improvements in quality or outcomes The 24% increase in price for daycase gall bladder surgery led to a 20% relative increase in daycase rates A Best Practice Tariff for fragility hip fractures led to faster surgery and better outcomes Best Practice Tariffs for stroke care had no effect on quality or outcomes

9. Lessons Incentives are always there, so make sure they are aligned Financial incentives appear to work when: –Big and high-profile (financially and/or reputationally) –Well-planned –Part of a multi-faceted improvement strategy –Supportive of a supported mission In health, seem more likely to produce positive spillovers Will be expensive if priced correctly but also cost-effective Require a clear maintenance and exit strategy

10. Financial incentives Levers for change in general practice and primary care, Nuffield Trust 6 November 2014 Matt Sutton