General practitioners and incentives

An evaluation of personal medical services: the times they are a changin'

The Personal Medical Services (PMS) pilot sites, launched in England in 1997 by the Secretary of State for the then Conservative government, introduced a local contract for primary care, aimed at promoting flexibility, innovation and policy participation. As part of the National Evaluation of PMS, this paper considers the professional and organisational relationships established between service providers working in those PMS sites which specifically set out to address inequalities in access to primary care for vulnerable populations. The introduction of PMS enabled a change of cultural values in primary care, particularly regarding GPs' relationships with nurses and practice staff. However, PMS has not necessarily led to equal partnerships within primary care teams. Rather,in the selected sites evaluated new interprofessional relationships emerged. There was evidence of intra and interprofessional partnerships being forged, providing the basis for further improved intersectoral collaboration. There was also evidence that the GP based medical model made way for a community oriented/public health model with emphasis on health maintenance for the vulnerable.

New labour and Britain's National Health Service: an overview of current reforms

Britain's National Health Service (NHS) has been the subject of unprecedented market reforms, which have failed to solve its problems. The New Labour government elected in 1997 has halted the drive toward the marketization of health care and replaced cost with quality as the central concern of NHS administration and policy. Major changes are occurring in the regulation of professional activity, with profound implications for the medical profession and the health service. The authors discuss these changes and possible future problems for the NHS.

The use of targets to improve the performance of health care providers: a discussion of government policy

The aim of this discussion paper is to examine the advantages and drawbacks of employing targets, or performance indicators, to improve the performance of those delivering health care services. The paper is based on an examination of two target-setting policies initiated by Government: the 1992 Health of the Nation strategy and the 1990 General Practitioners' Contract. It is argued that the introduction of both the General Practitioners' Contract and the Health of the Nation have indeed been accompanied by improvements in performance, however, there are a number of problems with targets. They tend to focus on those things that are most easily measured, and they may foster complacency on the part of providers who have already achieved upper target limits, and defensiveness on the part of those performing badly. National targets may skew local priorities; they may also be unrealistic and unattainable for particular, less privileged population groups. They may serve to widen inequalities in health, and can exacerbate the 'inverse care law' by encouraging providers to direct their efforts at the more advantaged sections of society, where such efforts are more likely to pay off in terms of overall improvements in the target level achieved. Finally, the achievement of some targets will not necessarily result in better health outcomes. The paper concludes that a target-setting approach to improving the quality of care must be based on the use of appropriate indicators, and must take account of differences between more and less advantaged sections of society.

Income-based incentives in UK general practice

Since 1990, income-based economic incentives have ostensibly become more important in the remuneration structure of UK general practitioners. For incentives to fulfil their role, however, GPs must possess discretion over income-generating activity and be assumed to be income maximisers. Evidence from one English health authority suggests that a very high proportion of GP income continues to be determined by patient characteristics and the scope for a discretionary response to income incentives is correspondingly small. Where discretion does exist, higher levels of GP incomes do not appear to militate against further discretionary income raising, except in the case where this income and budgetary discipline are in conflict.

Rapid prescribing change, how do patients respond?

The cost of prescribed medication is an increasing burden on health care systems. British general practitioners have been encouraged to reduce their prescribing costs through financial incentives within the fundholding scheme. This study reports on one general practice which reduced prescribing expenditure as part of the move to fundholding. Interviews performed with practice staff and patients were analysed and combined with prescribing statistics and questionnaire data to give a picture of the balance between the experience of patients and practitioners. Fifty-three interviews with 17 patients revealed that most were willing to try cheaper treatments and that dissatisfaction was primarily with the communication they received rather than the change itself. Each patient had to decide how to respond to the change in their medication. The decision-making process and the main factors involved are described and discussed. The experience of having long-standing treatment changed can have an impact on the doctor-patient relationship. This was not found to be a large problem and, it is suggested, can be guarded against. Large-scale economies in prescribing are feasible for some practices, and patients will tolerate such changes if attention is paid to sensitive communication.

Beyond guidelines: promoting clinical change in the real world

There is widespread recognition that simply publishing research findings is not enough to ensure that they are carried into clinical practice. One response to this has been the burgeoning "guidelines movement" of recent years, which has now reached the stage of generating guidelines for the production of guidelines. Argues that guidelines, and other forms of intervention to change clinical practice in an evidence-based direction, will succeed only to the extent that they engage actively with the real world of clinical decision making. This world is more complex than guidelines writers acknowledge, and includes economic, administrative, professional and personal incentives as well as those provided by research evidence. Engaging with this real world may be difficult, but it opens up new possibilities for understanding how clinicians act and how evidence may be used to inform clinical practice. Such possibilities include social influences, educational outreach, providing information to patients, negotiating local coalitions on specific issues and changing the administrative environment.

The carrot, the stick and the general practitioner: how have changes in financial incentives affected health promotion activity in general practice?

BACKGROUND

Financial incentives for increasing health promotion activity in primary care, introduced with the 1990 contract for general practitioners, were amended in 1993 and are now focused on cardiovascular disease. Payments for health promotion clinics were abolished and target payments were introduced.

AIM

The study aimed to evaluate the effect of the change, in June 1993, in financial incentives for health promotion activity in primary care on the distribution of health promotion payments in two family health services authorities.

METHOD

A retrospective study was undertaken in which data from two family health services authorities were used to determine the annual level of health promotion payments per 1000 practice population before and after the contractual amendment. Health promotion clinic payment data were analysed for 78 practices in Bedfordshire Family Health Services Authority and 85 practices in Kensington, Chelsea and Westminster Family Health Services Authority. Changes in health promotion payments were calculated and related to two measures of relative need: all cause standardized mortality ratios, for patients aged 74 years or less, of the electoral ward in which the practice is located; and the Jarman underprivileged area score. High relative need was defined as a standardized mortality ratio of over 100 or more than 25% of the practice population living in electoral wards with a Jarman score of over 30.

RESULTS

Health promotion payments were more evenly distributed after the change in June 1993 than before between the two family health services authorities and between general practices. Single-handed practices were carrying out more clinics in 1992 than multi-partner practices and consequently were one of the greatest financial losers as a result of the change. In addition, practices located in electoral wards with high relative needs lost proportionally more than those in electoral wards with lower needs.

CONCLUSION

Changes in the general practitioner health promotion contract have created new financial winners and losers. It now appears that health promotion payments are more evenly distributed but that the distribution is unrelated to need or treatment given. More evidence on the effectiveness of health promotion interventions is required before policies aimed at promoting better health through primary care can be fully evaluated.

Current prescribing in primary care in the UK. Effects of the indicative prescribing scheme and GP fundholding

The costs of drugs prescribed in primary care in the UK continue to rise despite a variety of government initiatives. Two of the major initiatives are considered here in detail: the Indicative Prescribing Scheme (IPS), and general practitioner (GP) fundholding, both of which began in 1991. Other more recent initiatives are also described, including the selected list, the Pharmaceutical Pricing Regulatory Scheme and the move to relicense drugs for nonprescription sale. The IPS has generally failed to control the rise in drug costs because of unrealistic targets, organisational difficulties (including the lack of adequate data to set budgets properly) and because there was neither incentive nor penalty to encourage compliance on the part of the GP. The IPS stresses cost containment, and makes little allowance for the consideration of quality of appropriateness of prescribing. Despite this disappointment, the IPS is continuing, and the future of the scheme is discussed here. GP fundholding, in contrast, has reduced the rate of rise of drug costs in participating GP practices, although it has not actually reduced drug costs. There have been a number of studies of this model, which are discussed here. The clear financial incentive to fundholders encourages them to restrain drug costs. Attempts to extend similar incentives to nonfundholding GPs are also described. Although there is a commitment on the part of the government to encourage and make use of data about economic evaluations of drug therapy and other medical interventions, so far the emphasis has been exclusively on cost containment. In this paper, we consider possible mechanisms by which this might be improved.