Friday, July 01, 2011

British GP bonuses 'lead to poor patient care' as financial incentives boost some treatments... but caused a decline in others

Bonus payments for GPs mean some patients are missing out on improved care, say researchers.

The financial incentives have led to better measuring of high blood pressure and cholesterol levels, a study shows. But in other areas of patient care which are not in the scheme improvements were ‘significantly below’ what was expected. These included measurements involving people suffering from arthritis, dementia and back pain.

Pay-for-performance targets were introduced in 2004 as part of a new contract for GPs to reward them for taking better care of patients. The scheme had an annual price tag of £1.8billion at the time and is now worth around £1billion. Around a quarter of GPs’ average income – currently £105,000 a year – is linked to achieving the targets.

But the study says there may be ‘unintended consequences’ to the scheme, which is known as the Quality and Outcomes Framework. The study, published last night in the British Medical Journal, looked at data from 500 UK general practices and trends in quality of care for 42 activities.

Of these, 23 measurements or treatments attracted a bonus payment including measuring blood pressure and smoking habits. A further 19 activities did not lead to extra money, including measurement of thyroid function or blood sugar levels in certain categories of patients.

For all activities, there was a general improvement in quality before incentives were introduced.

When bonuses were attached to some measurements, there was a significant increase in quality during the first year after the scheme came in. This levelled off after three years to a 4 per cent rise above what would have been expected without incentives.

For measurements that did not attract extra money, quality was ‘significantly worse’ after three years, with a 5 per cent drop compared with the improvement that would have been expected without incentives.

Dr Tim Doran, who led the research team, said financial incentives resulted in a quicker rate of improvement in some activities. But it was questionable whether this lasted, and whether patients whose conditions did not attract bonuses were being neglected.

Dr Doran, a clinical research fellow at Manchester University, said: ‘It’s not possible to incentivise everything. It does improve quality in the short to medium term but it has a small detrimental effect on activities that do not attract financial targets. ‘In the medium term these may have been slightly neglected.’

Dr Doran said there were limitations to ‘bonus’ schemes because they set priorities for care that might result in other areas such as depression receiving less attention, partly because it was harder to measure improvements. Earlier this year research found that targets set to improve high blood pressure and cut heart attacks and strokes ‘had no impact’.

Researchers, led by Dr Brian Serumaga, a Harvard Medical School fellow working at Nottingham University, investigated 470,000 patients with high blood pressure. They found ‘little evidence’ of effectiveness of pay for performance targets.

The Government has pledged to reform the way GPs are paid for targets in the face of criticism.

The British Medical Association says the Quality and Outcomes Framework was designed to ensure that patients received uniform high-quality care no matter where they lived in the country, and, by doing that, to improve public health over the long term.

A Department of Health spokesman said: ‘The Quality and Outcomes Framework and other incentives for GPs are insufficiently focused on outcomes, including patient experience. ‘We therefore intend to reform the payment system so that GPs are rewarded appropriately for improving patient outcomes.’


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