Doran

1. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Quality of primary care under the UK pay-for-performance scheme T Doran, C Fullwood, E Kontopantelis, D Reeves, J Valderas, S Campbell, M Roland National Primary Care Research and Development Centre University of Manchester CEO Forum Kananaskis, 16 February 2009 Doran Quality of care under the UK P4P scheme Doran

2. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Outline • The UK pay-for-performance scheme • Background • The Quality and Outcomes Framework • Results from Years 1-4 (2004-05 to 2007-08) • Overview • Achievement of targets • Inequalities in quality of care • Quality of care before and after the introduction of P4P • Identification of cases • Achievement of process indicators • Achievement of intermediate outcomes indicators • Quality of care for non-incentivised activities Quality of care under the UK P4P scheme Doran

3. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework Outline • The UK pay-for-performance scheme • Background • The Quality and Outcomes Framework • Results from Years 1-4 (2004-05 to 2007-08) • Overview • Achievement of targets • Inequalities in quality of care • Quality of care before and after the introduction of P4P • Identification of cases • Achievement of process indicators • Achievement of intermediate outcomes indicators • Quality of care for non-incentivised activities Quality of care under the UK P4P scheme Doran

4. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework Background Improving quality of UK primary care in the late 1990s • Recognition of the need for quality improvement • Acknowledgement of poor quality care by medical profession • Recognition of health inequalities by Government • Prioritisation of quality improvement initiatives by Department of Health (DH) • Additional funding for health services • Government increased funding to NHS • - £69bn (C$130bn) in 2004  £92bn (C$175bn) in 2008 • DH determined to address low morale in primary care • Quality improvement initiatives • National Service Frameworks for major chronic diseases • Audit, inspection and revalidation of doctors • Public release of outcomes data • Computerisation of patient records Quality of care under the UK P4P scheme Doran

5. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework The Quality and Outcomes Framework (QOF) The original framework • Introduced in April 2004 for all practices in the UK • Family practitioner income increased by ~25% dependent on performance against 146 quality indicators • Each indicator allocated between 0.5 and 56 points (1,050 in total) • Each point earns an average practice £76 (C$144) • Maximum of • £79,800 (C$151,600) per practice • £25,000 (C$47,500) per physician • Achievement scores are publicly reported • www.qof.ic.nhs.uk Quality of care under the UK P4P scheme Doran

6. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework The quality indicators Clinical indicators Quality of care under the UK P4P scheme Doran

7. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework The quality indicators Organisational indicators Quality of care under the UK P4P scheme Doran

8. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework New indicators for Year 3 (2006-07) Clinical indicators Quality of care under the UK P4P scheme Doran

9. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework Achievement thresholds CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg • Points: • 0 to 19 points • Income: • £0 to £1,444 • (C$ 2,744) Minimum threshold Maximum threshold Quality of care under the UK P4P scheme Doran

10. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Background The Quality and Outcomes Framework Protecting patients against inappropriate treatment Exception reporting • Physicians may exclude (‘exception report’) patients for whom targets are inappropriate • Discretionary exception reporting: • treatment not tolerated • patient terminally ill, exceptionally frail or has supervening condition • Non-discretionary exception reporting: • patient refuses intervention or repeatedly refuses to attend • patient newly registered or diagnosed • service not available to practice Quality of care under the UK P4P scheme Doran

11. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Outline • The UK pay-for-performance scheme • Background • The Quality and Outcomes Framework • Results from Years 1-4 (2004-05 to 2007-08) • Overview • Achievement of targets • Inequalities in quality of care • Quality of care before and after the introduction of P4P • Identification of cases • Achievement of process indicators • Achievement of intermediate outcomes indicators • Quality of care for non-incentivised activities Quality of care under the UK P4P scheme Doran

12. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Results for Years 1-4 Points scored and remuneration Quality of care under the UK P4P scheme NHS Information Centre (www.qof.ic.nhs.uk)

13. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Achievement of clinical targets Overall achievement for 50 ‘stable’ indicators Number of practices Mean: Year 1 82.3% Year 2 87.8% Year 3 89.7% Year 4 90.0% Percentage achievement Quality of care under the UK P4P scheme Doran

14. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Exclusion of patients Overall exception reporting rates for 50 ‘stable’ indicators Number of practices Mean: Year 2 7.1% Year 3 7.8% Year 4 7.1% Percentage excluded Quality of care under the UK P4P scheme Doran

15. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Overview Achievement of targets Inequalities in quality of care Inequality in quality of care Achievement by area deprivation quintile Reported achievement 2004-05 2005-06 2006-07 Quality of care under the UK P4P scheme Doran et al. Lancet 2008; 372: 728-736.

16. Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Outline • The UK pay-for-performance scheme • Background • The Quality and Outcomes Framework • Results from Years 1-4 (2004-05 to 2007-08) • Overview • Achievement of targets • Inequalities in quality of care • Quality of care before and after the introduction of P4P • Identification of cases • Achievement of process indicators • Achievement of intermediate outcomes indicators • Quality of care for non-incentivised activities Quality of care under the UK P4P scheme Doran

17. Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Incentivised process DM4: Smoking advice offered in previous 15 months (5 points) Quality of care under the UK P4P scheme Doran

18. Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Incentivised process DM11: Record of blood pressure in previous 15 months (3 points) Quality of care under the UK P4P scheme Doran

19. Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Incentivised intermediate outcome DM12: Last recorded blood pressure is ≤ 145/85 mmHg (17 points) Quality of care under the UK P4P scheme Doran

20. Prevalence Incentivised processes Incentivised outcomes Non-incentivised activities UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Non-incentivised patient group Record of blood pressure in last 15m, all patients aged 25-44 Quality of care under the UK P4P scheme Doran

21. Summary Intended outcomes Unintended outcomes Conclusions Summary Intended outcomes of the QOF • Improving quality of care • Achievement for most incentivised activities increased over the first 3 years, but there was little improvement in Year 4 • Improvement over underlying trend for processes with low baseline • Marginal improvement over trend for outcomes activities • Reducing variations in quality of care • The poorest performing practices improved at the fastest rate • Overall inequalities in quality of care for incentivised activities almost disappeared by Year 3 • Keeping physicians happy • Over 4,000 additional physicians recruited (15% increase) • Income of principals increased by 58% (£41,600/ C$79,000) • Income of salaried physicians increased by 3% (£2,200/ C$4,200) Quality of care under the UK P4P scheme Doran

22. Summary Intended outcomes Unintended outcomes Conclusions Summary Unintended outcomes of the QOF • Reducing quality of care • Quality of care for non-incentivised activities may have declined after the introduction of the QOF • Excluding patients • Practices in deprived areas excluded marginally more patients • Some practices struggling to hit maximum achievement thresholds inappropriately excluded patients in order to maximise income • Some practices removed patients from chronic disease registers • Patients have had little input to the QOF to date • Reducing staff morale • Pressure on staff to hit QOF targets has caused some dissatisfaction • Rewards from QOF have not been equitably distributed Quality of care under the UK P4P scheme Doran

23. Summary Intended outcomes Unintended outcomes Conclusions Conclusions Lessons from the UK’s experiment with pay-for-performance • Put the necessary infrastructure in place • Installation of computing systems subsidised by Government • Several years of audit and quality improvement preceded the QOF • Get physicians on-side • Indicators based on evidence (or at least expert opinion) • Generous remuneration for achieving targets • Establish a baseline • Quality of care was already improving when QOF introduced • Most practices were already achieving above the maximum thresholds • Regularly review the framework and the indicators • QOF reviewed and indicators updated every 1-2 years • In future the cost-effectiveness of indicators will be assessed by the National Institute for Health and Clinical Excellence (NICE) • Potential new indicators will be piloted • Local QOFs will be introduced to address local priorities Quality of care under the UK P4P scheme Doran

24. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Further reading Further reading Resources and papers on the UK QOF • Resources • Department of Health. The Quality and Outcomes Framework. Available from: http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/index.htm • The NHS Information Centre. Online GP Practice Results Database. Available from: http://www.qof.ic.nhs.uk/ • Published research • Ashworth M, Seed P, Armstrong D, Durbaba S, Jones R. The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework. British Journal of General Practice 2007: 57: 441-448. • Campbell S, Reeves D, Kontopantelis E, et al. Quality of primary care in England with the introduction of pay for performance. New England Journal of Medicine 2007; 351: 181-190. • Doran T, Fullwood C, Gravelle H, et al. Pay for performance programs in family practices in the United Kingdom. New England Journal of Medicine 2006; 355: 375-384. • Doran T, Fullwood C, Reeves D, et al. Exclusion of patients from pay-for-performance targets by English physicians. New England Journal of Medicine 2008; 359: 274-284. • Doran T, Fullwood C, Kontopantelis E, Reeves D. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet 2008; 372: 728-736. • Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: further evidence from the quality and outcomes framework. CHE Research Paper 32. York: Centre for Health Economics, 2008. • Gray J, Millett C, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnicity and quality of diabetes care in a health system with universal coverage: population-based cross sectional survey in primary care. J Gen Intern Med. 2007; 22(9): 1317-1320. • Guthrie B, McLean G, Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. British Journal of General Practice. 2006; 56: 836-841. • McDonald R, Harrison S, Checkland K, Campbell S, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. British Medical Journal 2007; 334: 1357-1362. • Roland M. Linking physicians’ pay to the quality of care – a major experiment in the United Kingdom. New England Journal of Medicine. 2004; 351: 1448-1454. Quality of care under the UK P4P scheme Doran

25. UK pay-for-performance scheme Results for 2004-05 to 2007-08 Quality pre- and post- QOF Further information: tim.doran@manchester.ac.uk Quality of care under the UK P4P scheme Doran