Improving quality of care: has Denmark anything to learn from the UK?

Martin RolandNational Primary Care Research and Development CentreUniversity of Manchester UK

How should doctors be paid?

Salary Do as little as possible for as few people as possible

Capitation Do as little as possible for as many people as possible

FFS Do as much as possible, whether or not it helps the patient

Quality Carry out a limited range of highly commendable tasks, but nothing else

DramatisPersonae

Content of presentation

• Variation in practice: the need for quality improvement in general practice

• What does research tell us about what makes a difference to quality of care

• UK government initiatives 1998-2003 – did they make a difference?

• Quality related pay 2003-2006 – intended and unintended consequences

Hypertensives with controlled BP 20% - 90%

Diabetics with HbA1 in last year 25% - 100%

Seddon ME et al. Quality in Health Care 2001; 10: 152.

Variation in quality of primary care: systematic review of literature from UK, Australia and New Zealand

“In acute diseases, doctors differ so much among themselves that a treatment which one thinks the best possible, another thinks is bad

Hippocrates 460-377BC

… and similar differences are to be found in the examination of intestines.”

Good practice allowance – first suggested in the UK in 1986

The conference said “No” to a Good Practice Allowance.

Dr Wilson said that the Good Practice Allowance was political and provocative. It was prepared by a government who only listened to philosophers and trendy professors.

Report from the British Medical Association BMJ 1986; 293: 1384-6

1980s

• Quality can’t be measured• There’s no such thing as a bad doctor

1990s in the UK

A decade of quality improvement initiatives, mainly from government.

But what improves quality?

Were the initiatives evidence based?

100% quality

% quality achieved

Baseline quality

GuidelinesAudit / feedback

Opinion leaders

Financial incentives

?All of these things- no magic bullet

Major UK initiatives• National standards• Clinical governance• Annual appraisal• Contracts• Public release • Patient safety• Collaboratives• Inspection

50

55

60

65

70

75

80

85

90

1997 1998 1999 2000 2001 2002 2003 2004

Ove

rall

scor

e (m

ax 1

00)

Angina

Diabetes

Asthma

Quality of care in the UK improved between 1998 and 2003

Quality of care in 42 representative English practices.

Campbell et al. BMJ 2005; 331: 1121-1123.

0

10

20

30

40

50

60

70

80

90

1996 1998 2000 2002 2004

Pe

rce

nta

ge

of

pa

tie

nts

Cholesterol < 5mmol/l

BP <150/90

Quality of care improved between 1998 and 2003(patients with coronary heart disease)

Quality of care in 42 representative English practices.

Campbell et al. BMJ 2005; 331: 1121-1123.

1980s

• Quality can’t be measured• There’s no such thing as a bad doctor

2000

• Care is too variable• Quality can be measured• Care can be improved• It’s expensive to provide high quality care• “We want to be paid and given resources for

providing high quality care”

2003 UK pay for performance scheme “Quality and outcomes framework”

25% of GPs’ income relates to a complex

set of 136 quality indicators

£1.8 billion additional funding

King Hammurabi B.C.1795-1750

“If a doctor has opened an abscess of the eye and has cured the eye, he shall take ten shekels of silver”

“If a doctor has opened an abscess of the eye and has caused the loss of the eye, the doctor’s fingers shall be cut off”

25% of income relating to 136 quality indicators

• Chronic disease management (Ten conditions)

• Practice organisation (Five areas)

• Patient experience

New contract for GPs:Quality and Outcomes Framework

Roland M. NEJM 2004; 351: 1448-54.

Seventy six clinical indicators covering:

Coronary heart disease and heart failure (15)

Stroke and transient ischaemic attack (10)

Hypertension (5)

Diabetes (18)

Epilepsy (4)

Hypothyroidism (2)

Mental health (5)

Asthma (7)

Chronic obstructive pulmonary disease (8)

Cancer (2)

 

 Roland M. NEJM 2004; 351: 1448-54.

CHD 7. The percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months.

Point score: from 1 point (25%) to 7 points (90%)

CHD 8. The percentage of patients with coronary heart disease whose last total cholesterol (measured in the last 15 months) is 190mg/dL or less

Point score: from 1 point (25%) to 16 points (60%)

Roland M. NEJM 2004; 351: 1448-54.

Exception reporting for clinical indicators

• Patient refused

• Not clinically appropriate

• Newly diagnosed or recently registered

• Already on maximum doses of medication

Roland M. NEJM 2004; 351: 1448-54.

56 organisational indicators:

Records (19)

Information to patients (8)

Education and training (9)

Practice management (10)

Medicines management (10)

Four indicators relating to patient experience:

Conducting and acting on the results of patient surveys (3)

Booking consultations intervals of 10 minutes or more (1)

What are the effects of this type of

financial incentive likely to be?

What might the effects be?

• Improved care

• Increased computerization / admin. costs

• More nurses, larger teams

• Fragmentation, less holistic approach

• Un-incentivized areas get worse care

• Gaming or misrepresentation

• Change in professional values

0

1000

2000

3000

4000

5000

550 650 750 850 950 1050

.

Practice performance in first year of new contract

Quality points per practice, out of a maximum of 1050

www.ic.nhs.uk/services/qof

50

60

70

80

90

100

1996 1998 2000 2002 2004 2006

Ove

rall

sco

re Angina

Diabetes

Asthma

Quality of care improved further between 2003 and 2005, following the introduction of financial incentives

2005 data extends the time series in 42 representative practices

reported by Campbell et al. BMJ 2005; 331: 1121-1123.

What might the effects be?

• Improved care

• Increased computerization / admin. costs

• More nurses, larger teams

• Fragmentation, less holistic approach

• Un-incentivized areas get worse care

• Gaming or misrepresentation

• Change in professional values

What might the effects be?

• Improved care

• Increased computerization / admin. costs

• More nurses, larger teams

• Fragmentation, less holistic approach

• Un-incentivized areas get worse care

• Gaming or misrepresentation

• Change in professional values

What might the effects be?

• Improved care

• Increased computerization / admin. costs

• More nurses, larger teams

• Fragmentation, less holistic approach

• Un-incentivized areas get worse care

• Gaming or misrepresentation

• Change in professional values

“There are some doctors who are more interested in the disease than the patient.

It seems a funny sort of attitude to me.”

What might the effects be?

• Improved care

• Increased computerization / admin. costs

• More nurses, larger teams

• Fragmentation, less holistic approach

• Un-incentivized areas get worse care

• Gaming or misrepresentation

• Change in professional values

Example of an unintended outcome

Indicator: Patients should be able to make an appointment to see a doctor within 48 hours

Response: Advanced Access – offer unlimited appointments ‘on the day’

Consequence: Patients are unable to book ahead, and can only book on the day

2006: new and more sophisticated indicator, based on patient questionnaire scores

The ward was full, so I put him in my room as he was moribund and screaming and I did not want to wake the ward. I examined him. He had obvious gross bilateral cavitation and a severe pleural rub. I thought the latter was the cause of the pain and screaming. I had no morphia, just aspirin, which had no effect. I felt desperate. I knew very little Russian and there was no-one on the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later. It was not the pleurisy that caused the screaming, but loneliness. I was ashamed of my misdiagnosis and kept my story secret.

Archie Cochrane. One man’s medicine: an autobiography.

What might the effects be?

• Improved care

• Increased computerization / admin. costs

• More nurses, larger teams

• Fragmentation, less holistic approach

• Un-incentivized areas get worse care

• Gaming or misrepresentation

• Change in professional values

Exception reporting for clinical indicators

• Patient refused

• Not clinically appropriate

• Newly diagnosed or recently registered

• Already on maximum doses of medication

Roland M. NEJM 2004; 351: 1448-54.

Estimated exception reporting rates

Doran et al. NEJM 2006; 355:375-384

Overall median 5.4%

Range 0% - 85.8%

n=8105 practices in England

05

1015

2025

Sta

ndar

dise

d ov

eral

l wei

ghte

d tr

unca

ted

exce

ptio

ns

-1 0 1 2 3 4Standardised percentage of the population w ho belong to an ethnic minority

exceptions local trend

What might the effects be?

• Improved care

• Increased computerization / admin. costs

• More nurses, larger teams

• Fragmentation, less holistic approach

• Un-incentivized areas get worse care

• Gaming or misrepresentation

• Change in professional values

“It will not provide the care for the whole

person. It doesn’t allow that I have sat in

this chair for over twenty years and I know

my patients really well. It doesn’t allow for

that. You can’t count that…and you can’t

count the caring element” [GP16]

Roland M, Campbell S, Bailey N, Whalley D, Sibbald B. Primary Health Care Research and Development 2006; 7: 70-78

They (the GPs) forget we’re actually

nurses. You’ve not stopped all day

because you have had ill patients.

And then they come in and tell you

that you are 1% down on a target

Practice Nurse

“We developed this zero tolerance of

blood pressure. No-one is allowed to

say ‘It’s a little bit up, leave it’ …. it’s

not acceptable.”

Senior GP

“When we’re not meeting a target, I will

go in and speak to them privately. I did do

one area of naming and shaming … that

did work quite well …they don’t want to

be seen as the GP who’s falling down.”

Senior GP, talking about other GPs in his

practice

I enjoy being given the autonomy to

manage the different diseases….

because we are actually meeting

targets, patient care has definitely

improved

Practice Nurse

Mercifully we’ve been able to put

the clock back … and get back to

the people agenda [GP2]

Roland M, Campbell S, Bailey N, Whalley D, Sibbald B. Primary Health Care Research and Development 2006; 7: 70-78

Changes in GP job satisfaction 1989-2005

2

3

4

5

6

1989 1991 1993 1995 1997 1999 2001 2003 2005

Job satisfactionon Warr CookWarr scale

Major reform

How should doctors be paid?

Salary Do as little as possible for as few people as possible

Capitation Do as little as possible for as many people as possible

FFS Do as much as possible, whether or not it helps the patient

Quality Carry out a limited range of highly commendable tasks, but nothing else

Health impact of financial incentives

Impact of increasing quality of care from present levels to highest levels specified in contract

No of cardiovascular events prevented per

5 years per 10,000

Cholesterol lowering in CHD 15.5 Blood pressure control in Hypertension 15.4

McElduff P. et al. Will changes in primary care improve health outcomes. Quality and Safety in Health Care 2004; 13: 191-197

“I thought you were supposed to tailor

care to every individual patient. I think it

takes away patient centered care. I don’t

think people appreciate being phoned up

all the time to be reminded to come in for

checks.”

(Practice Nurse)

50

60

70

80

90

100

1991 1992 1993 1994 1995 1996 1997 1998 1999

Percentage of practices reaching 80% cervical cytology target

Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423

50

60

70

80

90

100

1991 1992 1993 1994 1995 1996 1997 1998 1999

AffluentareasDeprivedareas

Percentage of practices reaching 80% cervical cytology target

Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423

Changes in management of coronary heart disease 1998-2003

0

10

20

30

40

50

60

70

80

Total cholesterol <5mmol/l BP 150/90 or less

1998 2003

Campbell et al. British Medical Journal 2005; 331: 1121-1123.

Quality of care for individuals is determined by:

• Access (can the patient get to care?)

• Effectiveness (is it any good when he / she does?)- clinical care- interpersonal aspects of care

Quality for populations is determined in addition by:

• Equity

• Efficiency

Campbell S, Roland M, Buetow S. Defining Quality of Care. Social Science and Medicine 2000; 51: 1611-1625.