TIM DORAN UNIVERSITY OF YORK EQUITY IN PRIMARY CARE PAYING FOR PERFORMANCE

TIM DORANUNIVERSITY OF YORK

EQUITY IN PRIMARY CARE

PAYING FOR PERFORMANCE

HEALTH INEQUALITYIMPACT OF PRIMARY CARE PAYING FOR PERFORMANCE

HEALTH INEQUALITIES IN ENGLAND

SOURCE: DORLING ET AL, GRIM REAPER’S ROAD MAP, BRISTOL 2008 PRIMARY CARE AND HEALTH DISPARITY

HEALTH INEQUALITYIMPACT OF PRIMARY CARE PAYING FOR PERFORMANCE

1948: THE NATIONAL HEALTH SERVICE

BEVERIDGE AND THE FIVE GIANTS PRIMARY CARE AND HEALTH DISPARITY

PRIMARY CARE UNDER THE NHS

SOURCE: COLLINGS, LANCET 1950; 6625: 555-585. PRIMARY CARE AND HEALTH DISPARITY

“Conditions are… bad enough to turn a good doctor into a bad one within a very short

time.”

“…at best… very unsatisfactory and at worst a positive source of public danger.”

REPEALING THE INVERSE CARE LAW

SOURCE: TUDOR HART ET AL, BMJ 1991; 302: 1509-1503. PRIMARY CARE AND HEALTH DISPARITY

GLYNCORRWGPOPULATION 190064% UNSKILLED

HEALTH CENTRE‘SCREENING’ FOR BP, SMOKING, CHOLESTEROL, DIABETES, LUNG FUNCTION, BMI, ALCOHOLISM

MORTALITY SMR 94 (-6%)(BLAENGWYNFI 16O)

HEALTH INEQUALITYIMPACT OF PRIMARY CARE PAYING FOR PERFORMANCE

QUALITY & OUTCOMES FRAMEWORK

OVERVIEW OF THE QUALITY & OUTCOMES FRAMEWORK PRIMARY CARE AND HEALTH DISPARITY

INTRODUCED 2004 (ALL UK GENERAL PRACTICES)

146 QUALITY INDICATORS COVERING:

• MANAGEMENT OF CHRONIC CONDITIONS

• ORGANISATION OF CARE

• PATIENT EXPERIENCE

INDICATORS WORTH 0.5-57 POINTS (TOTAL 1,000)

• 1 POINT = £125 (€145)

PRACTICES EXCLUDE INAPPROPRIATE PATIENTS

ACHIEVEMENT SCORES PUBLICLY REPORTED

E.G.: CONTROL OF BLOOD PRESSURE

CHD6: PERCENTAGE OF CHD PATIENTS WITH BP ≤150/90 MMHG PRIMARY CARE AND HEALTH DISPARITY

0 3 6 9 1215182124273033363942454851545760636669727578818487909396990

2

4

6

8

10

12

14

16

18

20

Percentage achievement

PO

INTS S

CO

RED

PERCENTAGE ACHIEVEMENT

LOWER THRESHOLD

UPPER THRESHOLD

POINTS: 0-19

PAYMENT: £0-1,444

IMPACT ON INEQUALITIES

SOURCE: DORAN ET AL. LANCET 2008; 372: 728-736.

REPO

RTED

AC

HIE

VEM

EN

T

2004/5 2005/6 2006/7

PRIMARY CARE AND HEALTH DISPARITY

IMPACT ON INEQUALITIES

DIABETES INDICATORS, BY DEPRIVATION QUINTILE PRIMARY CARE AND HEALTH DISPARITY

AC

HIE

VEM

EN

T

DEPRIVATION QUINTILE

PROCESSES OUTCOMES

NON-INCENTIVIZED ACTIVITIES

SOURCE: DORAN ET AL. BMJ 2011; 342: D3590.

AC

HIE

VEM

EN

T A

BO

VE P

RED

ICTED

PRIMARY CARE AND HEALTH DISPARITY

2004/5 2006/7

NO EFFECT

SYSTEM ADVANTAGES

ADDITIONAL REMUNERATION COMPARED WITH SYSTEM ‘G’

RELA

TIV

E G

AIN

PRIMARY CARE AND HEALTH DISPARITY

COMPUTING SYSTEM

VIEWS OF PRACTITIONERS

SOURCE: WEHRLI U, FUR ELISE PRIMARY CARE AND HEALTH DISPARITY

“It's a good idea – I think it makes things tangible and quantifies things…”

“…although I hate it. I do.”

SOURCE: MCDONALD ET AL. BMJ 2007; 334: 1357-1362. PRIMARY CARE AND HEALTH DISPARITY

TIM.DORAN@YORK.AC.UK

QUESTIONS?PAYING FOR PERFORMANCE

EQUITABLE CARE PROVISION?

PRIMARY CARE AND HEALTH DISPARITY

PATIE

NTS

PER

PH

YSIC

IAN

DEPRIVATION ‘DECILE’

DISTRIBUTION OF PRIMARY CARE PHYSICIANS (1996)