BMJ 2015;350:h1051 doi: 10.1136/bmj.h1051 (Published 2 March 2015)
Page 1 of 2
Editorials
EDITORIALS Does paying for performance in primary care save lives? Probably not, according to state of the art evidence from the UK Grant Russell director of research unit, professor of general practice research, head of school Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Notting Hill, Victoria 3168, Australia
Like most of us, health planners can’t resist an occasional look into a neighbour’s backyard. Sometimes the view is compelling enough to launch study tours, delegations, and professional exchanges. And there have been plenty of those sent to the National Health Service (NHS) since its inception in 1949. Outsiders have sought to learn from NHS innovations in team based care, commissioning, clinical governance,1 and, more recently, the “grand experiment” that became the Quality and Outcomes Framework (QOF).2 Forged by the tools, and inspired by the philosophies of evidence based medicine, the QOF has, since its introduction in 2003, dwarfed other attempts to bring pay for performance into primary care.3
In a linked paper (doi:10.1136/bmj.h904)—which may well turn out to be a seminal study of the impact of the QOF on population health—Kontopantelis and colleagues asked whether QOF performance at the practice level was associated with either all-cause mortality or with premature mortality attributed to incentivised conditions such as diabetes, hypertension, ischaemic heart disease, stroke, and chronic kidney disease.4 The authors used complex spatial analysis to link QOF scores in 8000 English general practices to mortality data from over 30 000 statistical regions (“lower super output areas”), each of which corresponds to populations of between 1500 and 3000 individuals. Their work hinges on the assumption that practice performance on the QOF should, in theory, be reflected in the health of communities served by those practices. Despite a reduction in mortality for the incentivised conditions in the study period, there was no relationship between practice QOF scores and standardised all-cause and specific-cause mortality rates of the incentivised conditions in corresponding regions. This lack of a relationship held for both 2011-12 standardised mortality rates and for trends in mortality rates between 2007 and 2012. There were, however, clear and sadly predictable associations between mortality and social deprivation, rurality, and the proportions of non-white people within populations.
The study helps clarify the population health impact of the world’s largest pay for performance scheme. Earlier assessments of the QOF’s impact on outcomes have been less direct—relying
on statistical modeling,5 intermediate outcomes (such as blood pressure6 and HbA1c7), or measures of healthcare use (such as emergency department presentations8).
Work of this substance is going to lead to some reflection in the backyard of the NHS. We may get to hear “I told you so” from those who have long seen the QOF programme as having undesirable consequences on routines of care, relational continuity, and on the relationship between physician and patient.9 Advocates of QOF may challenge the study’s complex methods, and others may speculate as to whether, given low inter-practice variability and a complex web of trends and comorbidities, it would ever be possible to measure regional differences in the QOF’s impact on population health. Regardless of the debate, practices may be excused if they are a little less enthusiastic when managing registers and compiling lists of QOF exceptions in the coming weeks and months. Despite the caution that always comes with translating work done in one jurisdiction to another, the work has clear lessons for those outside the UK. It represents another example of the value (and some of the inherent limitations) of using geographic information systems to unpick the complexities of health system performance. The link between outcomes and deprivation reminds us that, despite the cost and energy expended on optimising technical quality of clinical care, social determinants of health remain potent influences of population health outcomes.
Kontopantelis and colleagues’ findings bring into focus the overall intent of pay for performance programmes. If the QOF is fundamentally about generating benefits at the population level, work needs to be done to assure a better fit between measures and intended outcomes. While the authors’ suggestion of a greater alignment between incentives and risk factor modification would be a good start, there are some deeper considerations. The lack of population health impact may seem to sit at odds with Starfield and other’s observations that stronger primary care systems are associated with reduced mortality and improved population health.10 11 This seeming paradox reminds us that quality primary care has drivers and consequences that differ
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1051 doi: 10.1136/bmj.h1051 (Published 2 March 2015)
Page 2 of 2
EDITORIALS
by level of analysis.12 The QOF, in essence, equates quality with measures of technical quality of disease care (such as proportions of diabetic patients with appropriate HbA1c levels). By contrast, the population benefits of primary care are under the influence of broader and more complex dimensions of quality such as access, appropriateness, and system coordination.12 International primary care policy makers need to remember that the QOF was introduced into one of the world’s most mature primary care systems. It arose at a critical time in primary care in the UK13 and has helped to increase the income of practitioners and stabilize a profession under some threat. A decade of observational research on the QOF has shown that the programme can generate modest improvements in primary care processes.3 Kontopantelis and colleagues’ paper provides the best evidence we have as to its lack of impact on population health. The work will further inform the rich and ongoing debate about the content, priorities, and future of a pay for performance programme that has generated an extensive and, at times, contradictory literature.
Provenance and peer review: Commissioned, not peer reviewed. 1 2 3 4 5 6 7 8 9 10 11
Scally G, Donaldson LJ. The NHS’s 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61-5. Roland M. Linking physicians’ pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351:1448-54. Gillam SJ, Siriwardena AN, Steel N. Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review. Ann Fam Med 2012;10:461-8. Kontopantelis E, Springate D, Ashworth M, Webb R, Buchan I, Doran T. Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study. BMJ 2015;350:h904. Fleetcroft R, Parekh-Bhurke S, Howe A, Cookson R, Swift L, Steel N. The UK pay-for-performance programme in primary care: estimation of population mortality reduction. Br J Gen Pract 2010;60:e345-52. Lee JT, Netuveli G, Majeed A, Millett C. The effects of pay for performance on disparities in stroke, hypertension, and coronary heart disease management: interrupted time series study. PLoS One 2011;6:e27236. Vamos EP, Pape UJ, Bottle A, Hamilton FL, Curcin V, Ng A, et al. Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care. CMAJ 2011;183:E809-16. Harrison MJ, Dusheiko M, Sutton M, Gravelle H, Doran T, Roland M. Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study. BMJ 2014;349:g6423. Campbell SM, McDonald R, Lester H. The experience of pay for performance in English family practice: a qualitative study. Ann Fam Med 2008;6:228-34. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502. Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff (Millwood) 2013;32:686-94. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med 2009;7:293-9. Doran T, Roland M. Lessons from major initiatives to improve primary care in the United Kingdom. Health Aff (Millwood) 2010;29:1023-9.
There seems every chance that the study tours will continue.
12 13
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Cite this as: BMJ 2015;350:h1051 © BMJ Publishing Group Ltd 2015
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS Does paying for performance in primary care save lives? Probably not, according to state of the art evidence from the UK Grant Russell director of research unit, professor of general practice research, head of school Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Notting Hill, Victoria 3168, Australia
Like most of us, health planners can’t resist an occasional look into a neighbour’s backyard. Sometimes the view is compelling enough to launch study tours, delegations, and professional exchanges. And there have been plenty of those sent to the National Health Service (NHS) since its inception in 1949. Outsiders have sought to learn from NHS innovations in team based care, commissioning, clinical governance,1 and, more recently, the “grand experiment” that became the Quality and Outcomes Framework (QOF).2 Forged by the tools, and inspired by the philosophies of evidence based medicine, the QOF has, since its introduction in 2003, dwarfed other attempts to bring pay for performance into primary care.3
In a linked paper (doi:10.1136/bmj.h904)—which may well turn out to be a seminal study of the impact of the QOF on population health—Kontopantelis and colleagues asked whether QOF performance at the practice level was associated with either all-cause mortality or with premature mortality attributed to incentivised conditions such as diabetes, hypertension, ischaemic heart disease, stroke, and chronic kidney disease.4 The authors used complex spatial analysis to link QOF scores in 8000 English general practices to mortality data from over 30 000 statistical regions (“lower super output areas”), each of which corresponds to populations of between 1500 and 3000 individuals. Their work hinges on the assumption that practice performance on the QOF should, in theory, be reflected in the health of communities served by those practices. Despite a reduction in mortality for the incentivised conditions in the study period, there was no relationship between practice QOF scores and standardised all-cause and specific-cause mortality rates of the incentivised conditions in corresponding regions. This lack of a relationship held for both 2011-12 standardised mortality rates and for trends in mortality rates between 2007 and 2012. There were, however, clear and sadly predictable associations between mortality and social deprivation, rurality, and the proportions of non-white people within populations.
The study helps clarify the population health impact of the world’s largest pay for performance scheme. Earlier assessments of the QOF’s impact on outcomes have been less direct—relying
on statistical modeling,5 intermediate outcomes (such as blood pressure6 and HbA1c7), or measures of healthcare use (such as emergency department presentations8).
Work of this substance is going to lead to some reflection in the backyard of the NHS. We may get to hear “I told you so” from those who have long seen the QOF programme as having undesirable consequences on routines of care, relational continuity, and on the relationship between physician and patient.9 Advocates of QOF may challenge the study’s complex methods, and others may speculate as to whether, given low inter-practice variability and a complex web of trends and comorbidities, it would ever be possible to measure regional differences in the QOF’s impact on population health. Regardless of the debate, practices may be excused if they are a little less enthusiastic when managing registers and compiling lists of QOF exceptions in the coming weeks and months. Despite the caution that always comes with translating work done in one jurisdiction to another, the work has clear lessons for those outside the UK. It represents another example of the value (and some of the inherent limitations) of using geographic information systems to unpick the complexities of health system performance. The link between outcomes and deprivation reminds us that, despite the cost and energy expended on optimising technical quality of clinical care, social determinants of health remain potent influences of population health outcomes.
Kontopantelis and colleagues’ findings bring into focus the overall intent of pay for performance programmes. If the QOF is fundamentally about generating benefits at the population level, work needs to be done to assure a better fit between measures and intended outcomes. While the authors’ suggestion of a greater alignment between incentives and risk factor modification would be a good start, there are some deeper considerations. The lack of population health impact may seem to sit at odds with Starfield and other’s observations that stronger primary care systems are associated with reduced mortality and improved population health.10 11 This seeming paradox reminds us that quality primary care has drivers and consequences that differ
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1051 doi: 10.1136/bmj.h1051 (Published 2 March 2015)
Page 2 of 2
EDITORIALS
by level of analysis.12 The QOF, in essence, equates quality with measures of technical quality of disease care (such as proportions of diabetic patients with appropriate HbA1c levels). By contrast, the population benefits of primary care are under the influence of broader and more complex dimensions of quality such as access, appropriateness, and system coordination.12 International primary care policy makers need to remember that the QOF was introduced into one of the world’s most mature primary care systems. It arose at a critical time in primary care in the UK13 and has helped to increase the income of practitioners and stabilize a profession under some threat. A decade of observational research on the QOF has shown that the programme can generate modest improvements in primary care processes.3 Kontopantelis and colleagues’ paper provides the best evidence we have as to its lack of impact on population health. The work will further inform the rich and ongoing debate about the content, priorities, and future of a pay for performance programme that has generated an extensive and, at times, contradictory literature.
Provenance and peer review: Commissioned, not peer reviewed. 1 2 3 4 5 6 7 8 9 10 11
Scally G, Donaldson LJ. The NHS’s 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61-5. Roland M. Linking physicians’ pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351:1448-54. Gillam SJ, Siriwardena AN, Steel N. Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review. Ann Fam Med 2012;10:461-8. Kontopantelis E, Springate D, Ashworth M, Webb R, Buchan I, Doran T. Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study. BMJ 2015;350:h904. Fleetcroft R, Parekh-Bhurke S, Howe A, Cookson R, Swift L, Steel N. The UK pay-for-performance programme in primary care: estimation of population mortality reduction. Br J Gen Pract 2010;60:e345-52. Lee JT, Netuveli G, Majeed A, Millett C. The effects of pay for performance on disparities in stroke, hypertension, and coronary heart disease management: interrupted time series study. PLoS One 2011;6:e27236. Vamos EP, Pape UJ, Bottle A, Hamilton FL, Curcin V, Ng A, et al. Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care. CMAJ 2011;183:E809-16. Harrison MJ, Dusheiko M, Sutton M, Gravelle H, Doran T, Roland M. Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study. BMJ 2014;349:g6423. Campbell SM, McDonald R, Lester H. The experience of pay for performance in English family practice: a qualitative study. Ann Fam Med 2008;6:228-34. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502. Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff (Millwood) 2013;32:686-94. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med 2009;7:293-9. Doran T, Roland M. Lessons from major initiatives to improve primary care in the United Kingdom. Health Aff (Millwood) 2010;29:1023-9.
There seems every chance that the study tours will continue.
12 13
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Cite this as: BMJ 2015;350:h1051 © BMJ Publishing Group Ltd 2015
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
