Diabetes care not improved by pay incentives for primary care
5 June 2009
The care of patients with diabetes in the UK has improved over the
last decade, but this does not seem to be a direct result of the Quality
and Outcomes Framework — the scheme that rewards UK general practices
for delivering quality care.
The scheme in its present form may even lead to reduced levels of
care for some patients, say researchers in a paper published on bmj.com.
The quality and outcomes framework was introduced in 2004 to improve
standards of primary care by linking financial incentives to performance
indicators for all general practitioners in the UK. The management of
diabetes includes targets for controlling blood pressure, cholesterol
and blood glucose levels. Payments are staged and are subject to minimum
and maximum thresholds.
Since its introduction, a series of studies have suggested an
improvement in the management of people with diabetes in primary care,
but it is unclear whether this is a direct result of the scheme or
reflects existing trends in response to other quality improvement
So researchers based at the Universities of Birmingham and Manchester
assessed the proportion of patients meeting diabetes targets annually
between 2001 and 2007 (three years prior to and following the
introduction of the scheme). Their analysis included 147 general
practices covering over one million patients across the UK.
They found significant improvements in all of the diabetes targets
over the six-year period, with consecutive annual improvements observed
before the introduction of incentives.
However, these improvements in care appear to plateau after the
introduction of the framework.
This could reflect the increasing difficulty of target attainment in
poorly controlled patients, say the authors. However, it may also
reflect the lack of further incentive after attainment of the upper
payment thresholds (the ceiling effect).
If so, they suggest that upper thresholds may need to be removed or
targets made more challenging if people are to benefit.
Another important finding was that up to two thirds of people with
type 1 diabetes and a third of people with type 2 diabetes were not
captured in the framework assessment. This needs to be addressed to
reduce health inequalities, say the authors.
The authors say that their work and that of others highlights the
potential unintended consequences of the scheme and raises concerns that
the quality and outcomes framework may not have been as efficient in
reducing inequalities in health in diabetes as was hoped.
Although the management of patients with diabetes has improved since
the late 1990s, the impact of the pay-for-performance initiative on care
is not straightforward, they conclude.
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