Skip to main content

Exclusion of patients from pay-for-performance programmes may widen health inequalities

Public reporting of physician and provider performance has become a key component of strategies to improve the quality of health care. Public reporting of performance is also increasingly being linked to provider pay through pay for performance programmes. Many pay for performance schemes permit physicians to exclude selected patients from performance indicators. For example, the Quality and Outcomes Framework (QOF), a major pay for performance scheme introduced into UK primary care in 2004, permits general practitioners to ‘exception report’ patients using set criteria. The criteria include circumstances where a treatment is not clinically appropriate, e.g. achieving tight blood glucose control in a diabetes patient with terminal cancer, or where a patient refuses to attend a review after three clinic invitations.

In a paper published recently in the Journal Diabetic Medicine, Andrew Dalton and colleagues examined associations between patient and practice characteristics and exclusions from quality indicators for diabetes using data from the first three years of the Quality and Outcomes Framework. They carried out three cross-sectional analyses using data from the electronic medical records of all patients with diabetes registered in 23 general practices in Brent, North West London between 2004/2005 and 2006/2007. They found that excluded patients were less likely to achieve treatment targets for HbA1c, blood pressure and cholesterol control. Black and South Asian patients were more likely to be excluded from the HbA1c indicator than White patients. Patients diagnosed with diabetes duration of > 10 years, those patients with co-morbidities and older patients were also more likely to be excluded. Larger practices also excluded more patients from the HbA1c indicator. More deprived practices consistently excluded more patients from all indicators.

The findings of the study suggest that patients excluded from pay-for-performance programmes may be less likely to achieve treatment goals and disproportionately come from disadvantaged groups. One key implication of these findings is that allowing physicians to exclude patients from pay-for-performance programmes may worsen health inequalities.


Popular posts from this blog

Improving how secondary care and general practice in England work together: the NHS Standard Contract

Due to the increasing pressures on general practices within the National Health Service in England, the interface between primary and secondary care, and the division of labour between these, has become an important issue. This has long been an area prone to difficulties and conflict, the consequences of which can directly impact the quality and safety of patient care, particularly for patients with chronic conditions who regularly transition between these two sectors. In an article published in the Journal of the Royal Society of Medicine, Amy Price and I explore the measures recently implemented in the NHS Standard Contract which aim to target common issues at the primary–secondary care interface, with an aim to reducing inappropriate general practitioner workload in England. We discuss the context behind the implementation of the NHS Standard Contract as well as current concerns and areas for further consideration.

The current crisis in primary care means the NHS Standard Contract…

Patients are more satisfied with general practices managed by GP partners than those managed by companies

General practices in England are independent businesses that are contracted to provide primary care for specified populations. Most are owned by general practitioners, but many types of organisation are now eligible to deliver these services. In a study published in the Journal of the Royal Society of Medicine, we examined the association between patient experience and the contract type of general practices in England, distinguishing limited companies from other practices.

We analysed data from the English General Practice Patient Survey 2013–2014 (July to September 2013 and January to March 2014). Patients were eligible for inclusion in the survey if they had a valid National Health Service number, had been registered with a general practice for six months or more, and were aged 18 years or over. All general practices in England with eligible patients were included in the survey (n = 8017).

Patients registered to general practices owned by limited companies reported worse experience…

Dr Demis Hassabis, Co-Founder and CEO of DeepMind, Speaks about AI in Healthcare

On 28 September 2017, I attended the Annual Institute of Global Health Innovation Lecture: Artificial General Intelligence and Healthcare, delivered by Dr Demis Hassabis, co-founder and CEO of Google DeepMind. Artificial intelligence is the science of making machines smart argued Dr Hassabis, so how can we make it improve the healthcare sector? Dr Hassabis then went on to describe the work that DeepMind was carrying out in healthcare in areas such as organising information, deep learning to support the reporting of medical images (such as scans and pathology slides), and biomedical science. Dr Hassabis also discussed the challenges of applying techniques such as reinforcement learning in healthcare. He concluded that artificial intelligence has great scope for improving healthcare; for example, by prioritising the tasks that clinicians had to carry out and by providing decision support aids for both patients and doctors. Dr Hassabis also discussed some of the ethical issues in using …