Background In 2004, after a series of national initiatives associatedwith marked improvements in the quality of care, the NationalHealth Service of the United Kingdom introduced a pay-for-performancecontract for family practitioners. This contract increases existingincome according to performance with respect to 146 qualityindicators covering clinical care for 10 chronic diseases, organizationof care, and patient experience.
Methods We analyzed data extracted automatically from clinicalcomputing systems for 8105 family practices in England in thefirst year of the pay-for-performance program (April 2004 throughMarch 2005), data from the U.K. Census, and data on characteristicsof individual family practices. We examined the proportion ofpatients deemed eligible for a clinical quality indicator forwhom the indicator was met (reported achievement) and the proportionof the total number of patients with a medical condition forwhom a quality indicator was met (population achievement), andwe used multiple regression analysis to determine the extentto which practices achieved high scores by classifying patientsas ineligible for quality indicators (exception reporting).
Results The median reported achievement in the first year ofthe new contract was 83.4 percent (interquartile range, 78.2to 87.0 percent). Sociodemographic characteristics of the patients(age and socioeconomic features) and practices (size of practice,number of patients per practitioner, age of practitioner, andwhether the practitioner was medically educated in the UnitedKingdom) had moderate but significant effects on performance.Exception reporting by practices was not extensive (median rate,6 percent), but it was the strongest predictor of achievement:a 1 percent increase in the rate of exception reporting wasassociated with a 0.31 percent increase in reported achievement.Exception reporting was high in a small number of practices:1 percent of practices excluded more than 15 percent of patients.
Conclusions English family practices attained high levels ofachievement in the first year of the new pay-for-performancecontract. A small number of practices appear to have achievedhigh scores by excluding large numbers of patients by exceptionreporting. More research is needed to determine whether thesepractices are excluding patients for sound clinical reasonsor in order to increase income.
Source Information
From the National Primary Care Research and Development Centre, University of Manchester, Manchester, United Kingdom.
Address reprint requests to Dr. Doran at the National Primary Care Research and Development Centre, Williamson Bldg., University of Manchester, Manchester M13 9PL, United Kingdom, or at tim.doran{at}manchester.ac.uk.
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