Elsevier

The Lancet

Volume 372, Issue 9640, 30 August–5 September 2008, Pages 728-736
The Lancet

Articles
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

https://doi.org/10.1016/S0140-6736(08)61123-XGet rights and content

Summary

Background

The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme.

Methods

We analysed data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004–05 to 2006–07).

Findings

Median overall reported achievement 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. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86·8% (82·2–89·6) for quintile 1 (least deprived) to 82·8% (75·2–87·8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4·4% for quintile 1 and by 7·6% for quintile 5, and the gap in median achievement narrowed from 4·0% to 0·8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0·0001), but was not associated with area deprivation (p=0·062).

Interpretation

Our results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation.

Funding

None.

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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