ArticlesEffect 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
Introduction
In 1997, the UK Government made an explicit commitment to tackle health inequalities, and has since pursued several social and health policies to this end.1, 2, 3 The National Health Service (NHS) was targeted with an ambitious programme of initiatives to improve quality that aimed to eliminate unacceptable variations in the standard of health care.3, 4 The UK Government reiterated its original commitment by making health inequalities a health-service priority for 2008–09, with the specific objective of improving life expectancy in areas with the worst health and deprivation. Primary-care services are intended to have a central role in achieving this objective.5
The most substantial UK Government intervention in primary care was the re-negotiation of the national contract with general practitioners in 2003. At the core of the new contract was the quality and outcomes framework, which links financial incentives to the quality of care that is provided by practices.6 Quality is measured against a set of clinical activity indicators relating to aspects of care for several common chronic diseases, with practices rewarded according to the proportion of eligible patients for whom each target is achieved. Further payments are awarded for aspects of practice organisation and for administering patient surveys. To protect patients from inappropriate care, the scheme allows practices to exclude patients who they deem inappropriate from specific indicators, for reasons such as extreme frailty, intolerance of a particular drug, and declining treatment.7
In the first full year of the scheme (2004–05), practices generally reported high levels of achievement for the clinical indicators,8 and levels of achievement have, on average, increased every year for most indicators.9 However, there are concerns that practices serving deprived populations have achieved lower levels of performance,10 have received less generous financial rewards,11 and might have excluded more patients than have those serving more affluent populations.12 If this tenet is true, the incentive scheme could be driving an overall increase in quality of care at the cost of widening existing health inequalities, and hence undermining Government policy.
The early years of public-health interventions are often damaging in terms of health equity.13, 14, 15, 16 Victora and colleagues' inverse equity hypothesis17 proposes that affluent sections of society preferentially benefit from, or exploit, such interventions, leading to an initial increase in inequalities, and deprived sections only begin to catch up once affluent sections of society have extracted maximum benefit. Health inequalities ultimately diminish because people in deprived areas start with a lower baseline level of health and health-care uptake.
We aimed to examine the pattern of socioeconomic inequalities with respect to delivered quality of clinical care in the first 3 years of the incentive scheme in England and to changes in quality of clinical care during this time. We examined both patterns in achievement against the clinical quality indicators and in the number of patients who were excluded from the scheme by practices.
Section snippets
The quality and outcomes framework
General practices in England provide primary-care services for a defined population (mean 6226 [SD 3869] patients). For the clinical indicators on the quality and outcomes framework, practices are awarded points on a sliding scale on the basis of the proportion of eligible patients for whom they achieve every target. The minimum achievement threshold is 25% (ie, practices must achieve the target for at least 25% of patients to receive any points) and the maximum threshold varies according to
Results
The median overall reported achievement—the proportion of patients who were deemed eligible by the practices for whom the targets were achieved—was 85·1% (IQR 79·0–89·1) in year 1, 89·3% (86·0–91·5) in year 2, and 90·8% (88·5–92·6) in year 3. Increases in achievement between years were significant (p<0·0001 in all cases). Although average levels of achievement increased over time, variation in achievement diminished.
In year 1, progressively lower levels of achievement were associated with
Discussion
Our study has shown that variation in the quality of care related to deprivation was reduced during the first 3 years of the financial incentive scheme. The quality and outcomes framework was intended to improve the general quality of primary care and to eliminate variation between providers by resourcing and rewarding best practice.21 In the first 3 years of the scheme, more than £2 billion additional funding was provided for primary-care services: information technology systems were rapidly
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