Stephen Gillam

Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework—A Systematic Review

PURPOSE Primary care practices in the United Kingdom have received substantial financial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This article reviews the growing evidence for the impact of the framework on the quality of primary medical care. METHODS Five hundred seventy-five articles were identified by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modified Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review. RESULTS Quality of care for incentivized conditions during the first year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients’ satisfaction with continuity declined, with little change in other domains of patient experience. CONCLUSIONS Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefits of similar schemes.

Effects of payment for performance in primary care: qualitative interview study.

Objectives To understand the effects of a large scale ‘payment for performance’ scheme (the Quality and Outcomes Framework [QOF]) on professional roles and the delivery of primary care in the English National Health Service. Methods Qualitative semi-structured interview study. Twenty-four clinicians were interviewed during 2006: one general practitioner and one practice nurse in 12 general practices in eastern England with a broad range of sociodemographic and organizational characteristics. Results Participants reported substantial improvements in teamwork and in the organization, consistency and recording of care for conditions incentivized in the scheme, but not for non-incentivized conditions. The need to carry out and record specific clinical activities was felt to have changed the emphasis from ‘patient led’ consultations and listening to patients’ concerns. Loss of continuity of care and of patient choice were described. Nurses experienced increased workload but enjoyed more autonomy and job satisfaction. Doctors acknowledged improved disease management and teamwork but expressed unease about ‘box-ticking’ and increased demands of team supervision, despite better terms and conditions. Doctors were less motivated to achieve performance indicators where they disputed the evidence on which they were based. Participants expressed little engagement with results of patient surveys or patient involvement initiatives. Some participants described data manipulation to maximize practice income. Many felt overwhelmed by the flow of policy initiatives. Conclusions Payment for performance is driving major changes in the roles and organization of English primary health care teams. Non-incentivized activities and patients’ concerns may receive less clinical attention. Practitioners would benefit from improved dissemination of the evidence justifying the inclusion of new performance indicators in the QOF.

Is the declaration of Alma Ata still relevant to primary health care

Thirty years after WHO highlighted the importance of primary health carein tackling health inequality in every country, Stephen Gillam reflects on the reasons for slow progress and the implications for today’s health systems

HEALTH PROMOTION IN PRIMARY CARE

In his continuing drive to appease disillusioned and overworked general practitioners, Britains secretary of state for health has made major concessions over the data on health promotion that general practitioners are required to record.1 The more than 120 items of data that were previously required have now been reduced to eight. The move will please those general practitioners who have objected to the “ritualistic collection of risk factors when the public health benefits are marginal,”2 but the reductions seem to have been driven more by the pressure to reduce paperwork than by a desire for effective disease prevention. In the absence of either a strategic or an evidence based approach to health promotion in primary care, many important items have been lost while others have been inappropriately retained. Under the new scheme, general practitioners are being asked to record the number of patients in …

Undergraduate public health education in UK medical schools ) struggling to deliver

Introduction  Recent policy initiatives in the United Kingdom (UK) have underlined the importance of public health education for health care professionals. We aimed to describe teaching inputs to medical undergraduate curricula, to identify perceived challenges in the delivery of public health teaching and strategies that may overcome them.

Rising hospital admissions.

Can the tide be stemmed?

Global health education in U.S. Medical schools

Interest in global health (GH) among medical students worldwide is measurably increasing. There is a concomitant emphasis on emphasizing globally-relevant health professions education. Through a structured literature review, expert consensus recommendations, and contact with relevant professional organizations, we review the existing state of GH education in US medical schools for which data were available. Several recommendations from professional societies have been developed, along with a renewed emphasis on competencies in global health. The implementation of these recommendations was not observed as being uniform across medical schools, with variation noted in the presence of global health curricula. Recommendations for including GH in medical education are suggested, as well as ways to formalize GH curricula, while providing flexibility for innovation and adaptation

Public health education for medical students: rising to the professional challenge

Public health competencies, especially as they relate to the management of chronic disease, will be of increasing importance to the global health-care workforce. The General Medical Councils recommendations on basic medical education have helped to entrench the position of public health and related disciplines. Tomorrows Doctors has recently been updated. This article describes the indicative goals that should underpin the development of undergraduate medical education in public health, presented in a national statement. The statement was originally produced on behalf of academic departments of public health and related disciplines in UK medical schools. The dearth of evidence in this field leaves many questions for future educational research.

Teaching doctors in training about management and leadership.

New frameworks help but old obstacles hamper progress

The Quality and Outcomes Framework—where next?

The UK’s pay for performance system for primary care has produced some benefits, including reducing inequalities between practices, but Stephen Gillam and Nicholas Steel argue that it is time to reduce the proportion of general practitioners’ income that it governs