Fundholding in northern region: the first year

Fund-holding and commissioning general practitioners

General practice fund-holders purchase secondary care for their patients directly, encouraging competition between providers. The scheme now includes almost all community mental health services. Practice counsellors may now be funded from secondary care budgets. Fund-holders may use their purchasing power to influence out-patient policies, have consultant sessions in their surgeries, gain direct referral to community psychiatric nurses, resist sectorisation, or change to a different provider altogether. The implications for mental health teams and their patients are discussed. Mental health workers must define their roles very dearly, and get involved in negotiating contracts now, to influence future service provision.

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories. Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care. Financial incentives seeking to influence prescribers' behaviour include budgetary arrangements at primary care and hospital settings (pharmaceutical budget caps or targets), financial rewards for target behaviours or outcomes (pay for performance interventions) and reduced benefit margin for prescribers based on medicine sales and prescriptions (pharmaceutical reimbursement rate reduction policies). This is the first update of the original version of this review.

OBJECTIVES

To determine the effects of pharmaceutical policies using financial incentives to influence prescribers' practices on drug use, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (searched 29/01/2015); MEDLINE, Ovid SP (searched 29/01/2015); EMBASE, Ovid SP (searched 29/01/2015); International Network for Rational Use of Drugs (INRUD) Bibliography (searched 29/01/2015); National Health Service (NHS) Economic Evaluation Database (searched 29/01/2015); EconLit - ProQuest (searched 02/02/2015); and Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge (citation search for included studies searched 10/02/2015). We screened the reference lists of relevant reports and contacted study authors and organisations to identify additional studies.

SELECTION CRITERIA

We included policies that intend to affect prescribing by means of financial incentives for prescribers. Included in this category are pharmaceutical budget caps or targets, pay for performance and drug reimbursement rate reductions and other financial policies, if they were specifically targeted at prescribing or drug utilisation. Policies in this review were defined as laws, rules, regulations and financial and administrative orders made or implemented by payers such as national or local governments, non-government organisations, private or social insurers and insurance-like organisations. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes or costs. The study had to be a randomised or non-randomised trial, an interrupted time series (ITS) analysis, a repeated measures study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies and risks of bias using Cochrane Effective Practice and Organisation of Care (EPOC) criteria and extracted data from the included studies. For CBA studies, we reported relative effects (e.g. adjusted relative change). The review team re-analysed all ITS results. When possible, the review team also re-analysed CBA data as ITS data.

MAIN RESULTS

Eighteen evaluations (six new studies) of pharmaceutical policies from six high-income countries met our inclusion criteria. Fourteen studies evaluated pharmaceutical budget policies in the UK (nine studies), two in Germany and Ireland and one each in Sweden and Taiwan. Three studies assessed pay for performance policies in the UK (two) and the Netherlands (one). One study from Taiwan assessed a reimbursement rate reduction policy. ITS analyses had some limitations. All CBA studies had serious limitations. No study from low-income or middle-income countries met the inclusion criteria.Pharmaceutical budgets may lead to a modest reduction in drug use (median relative change -2.8%; low-certainty evidence). We are uncertain of the effects of the policy on drug costs or healthcare utilisation, as the certainty of such evidence has been assessed as very low. Effects of this policy on health outcomes were not reported. Effects of pay for performance policies on drug use and health outcomes are uncertain, as the certainty of such evidence has been assessed as very low. Effects of this policy on drug costs and healthcare utilisation have not been measured. Effects of the reimbursement rate reduction policy on drug use and drug costs are uncertain, as the certainty of such evidence has been assessed as very low. No included study assessed the effects of this policy on healthcare utilisation or health outcomes. Administration costs of the policies were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Although financial incentives are considered an important element in strategies to change prescribing patterns, limited evidence of their effects can be found. Effects of policies, including pay for performance policies, in improving quality of care and health outcomes remain uncertain. Because pharmaceutical policies have uncertain effects, and because they might cause harm as well as benefit, proper evaluation of these policies is needed. Future studies should consider the impact of these policies on health outcomes, drug use and overall healthcare expenditures, as well as on drug expenditures.

The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services?

Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

Pharmaceuticals, while central to medical therapy, pose a significant burden to health care budgets. Therefore regulations to control prescribing costs and improve quality of care are implemented increasingly. These include the use of financial incentives for prescribers, namely increased financial accountability using budgets and performance based payments.

OBJECTIVES

To determine the effects on drug use, healthcare utilisation, health outcomes and costs (expenditures) of policies, that intend to affect prescribers by means of financial incentives.

SEARCH STRATEGY

We searched the following databases and web sites: Effective Practice and Organisation of Care Group Register (August 2003), Cochrane Central Register of Controlled Trials (October 2003), MEDLINE (October 2005), EMBASE (October 2005), and other databases.

SELECTION CRITERIA

Policies were defined as laws, rules, financial and administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes, and costs. The study had to be a randomised or non-randomised controlled trial, interrupted time series analysis, repeated measures study or controlled before-after study evaluating financial incentives for prescribers introduced for a jurisdiction or healthcare system.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study limitations.

MAIN RESULTS

Thirteen evaluations of budgetary policies and none of performance based payments met our inclusion criteria. Ten studies evaluated general practice fundholding in the UK, one the Irish Indicative Drug Target Savings Scheme (IDTSS) and two evaluated German drug budgets for physicians in private practice. The interrupted time series analyses had some limitations. All the controlled before-after studies (all from the UK) had serious limitations. Drug expenditure (per item and per patient) and prescribed drug volume decreased with budgets in all three countries. Evidence indicated increased use of generic drugs in the UK and Ireland, but was inconclusive on the use of new and expensive drugs. We found no clear evidence of increased health care utilisation and no studies reporting effects on health. Administration costs were not reported. No studies on the effects of performance-based payments or other policies met our inclusion criteria.

AUTHORS' CONCLUSIONS

Based on the evidence in this review from three Western European countries, drug budgets for physicians in private practice can limit drug expenditure by limiting the volume of prescribed drugs, increasing the use of generic drugs or both. Since the majority of studies included were found to have serious limitations, these results should be interpreted with care.

Management in general practice: the challenge of the new General Medical Services contract

BACKGROUND

Managers in general practice perform a variety of roles, from purely administrative to higher-level strategic planning. There has been little research investigating in detail how they perform these roles and the problems that they encounter. The new General Medical Services (GMS) contract contains new management challenges and it is not clear how practices will meet these.

AIM

To improve understanding of the roles performed by managers in general practice and to consider the implications of this for the implementation of the new GMS contract.

DESIGN OF STUDY

In-depth qualitative case studies covering the period before and immediately after the vote in favour of the new GMS contract.

SETTING

Three general practices in England, chosen using purposeful sampling.

METHOD

Semi-structured interviews with all clinical and managerial personnel in each practice, participant and non-participant observation, and examination of documents.

RESULTS

Understanding about what constitutes the legitimate role of managers in general practice varies both within and between practices. Those practices in the study that employed a manager to work at a strategic level with input into the direction of the organisation demonstrated significant problems with this in practice. These included lack of clarity about what the legitimate role of the manager involved, problems relating to the authority of managers in the context of a partnership, and lack of time available to them to do higher-level work. In addition, general practitioners (GPs) were not confident about their ability to manage their managers' performance.

CONCLUSION

The new GMS contract will place significant demands on practice management. These results suggest that it cannot be assumed that simply employing a manager with high-level skills will enable these demands to be met; there must first be clarity about what the manager should be doing, and attention must be directed at questions about the legitimacy enjoyed by such a manager, the limits of his or her authority, and the management of performance in this role.

A healthy disposition? The use and limitations of the characteristics approach to general practice research

A range of easily identifiable characteristics is often used by researchers and general practitioners to categorise primary care practices. In the United Kingdom, for example, practices can be defined as dispensing, single-handed or training. The availability of routinely collected data has led to a growing research literature that links practice characteristics to their workload, performance and costs. This paper examines the use and limitations of this 'characteristics approach' and argues that this type of research is often undertaken because it is easy to perform rather than because it is the most appropriate way to study primary care. Using this approach may lead to failure to do the following: to account for the environmental factors that determine the effects particular characteristics manifest; to identify the true relationships between the observed characteristics; to control for changes in the effects of characteristics over time; to differentiate between the behaviour of individual members of a group with the same characteristic and that of the group as a whole; to assign the correct causality to relationships between practice characteristics, workloads, performance, and costs. The characteristics approach should be used with great caution by general practice researchers.

Addressing the inequity of capitation by variable soft contracts

In the search for greater efficiency and cost-containment, many health systems have introduced the practice of medical care providers operating under a fixed budget, often referred to as the capitation or fundholding contract. Although the capitation contract seems equitable at first glance, the sequential decision-making practice of providers-shaped by their rate of present-preference and their attitude toward the risk of running out of budget-may result in serious violations of basic equity principles. We propose a variable soft (or mixed) payment contract (VSC), where the share of the retrospective payment increases over time, as a way to make the contracts more equitable. We also discuss how the parameters of the capitation contract (length of the budget period, soft or hard contracts, solo vs. consortium practice etc.), which are usually set by efficiency criteria, may have serious implications with regard to the equity of the system.

Did the introduction of general practice fundholding change patterns of emergency admission to hospital?

OBJECTIVES

To test the hypothesis that the introduction of general practice fundholding was associated with a change in the proportion of emergency admissions to hospital.

METHODS

Before and after natural experiment with control group. The experimental group was first-wave fundholding general practices in the South Western Regional Health Authority, the control group was all practices that remained non-fundholding as of April 1993. Data were collected on episodes of care in hospitals in the South Western region involving cholecystectomy, hernia repair, intervertebral disc operation and prostatectomy. The additional impact of fundholding status on any underlying changes in proportions of emergency admissions was examined using multiple logistic regression.

RESULTS

There was no evidence of an interaction between fundholding status and before/after time period. Odds ratios and confidence intervals for the interaction of general practice fundholding status and time were: prostatectomy 1.02 (0.77 to 1.34); hernia repair 0.94 (0.7 to 1.24); intervertebral disk operations 1.67 (0.8 to 3.47); prostatectomy 0.94 (0.69 to 1.27).

CONCLUSIONS

The results provide no evidence that, in the first 2 years of the scheme, fundholding had an impact on the proportion of emergency admissions to hospital.

General practitioner fundholding: weighing the evidence

A new development in the British National Health Service is fundholding, whereby certain general practitioners are given budgets from which they purchase services for patients. Our knowledge about fundholding is rudimentary. Many important questions remain unanswered. These include: the impact of fundholding on the efficiency of overall resource utilisation; its effect on strategic planning; its effect on equity; its impact on the role of the doctor and the doctor-patient relationship; and its consequences for practice organisation and the culture of primary care. Even the scant results we do have must be interpreted cautiously. Fundholding was introduced during a period of great turbulence for general practice. Its strategic function was uncertain and its impact has been confounded by the effects of a series of earlier and concurrent policy changes. Few reliable conclusions about fundholding, either positive or negative, can be drawn from existing research.

What do we known about fundholding in general practice?

The general practice fundholding scheme was introduced four years ago. So far its impact has not been formally evaluated nationally, but review of published research shows some trends. Fundholding has curbed prescribing costs and given general practitioners greater power to lever improvements in hospital services--for example, reducing waiting times for hospital treatment--but fundholding practices may have received more money than non-fundholding practices. The impact of fundholding on transactions costs, equity, and quality of care (particularly for patients of non-fundholding general practitioners) is unknown. Research into costly reforms such as fundholding needs to be coordinated.

Care of patients with selected health problems in fundholding practices in Scotland in 1990 and 1992: needs, process and outcome

BACKGROUND

At the time of the introduction of fundholding, a number of potential benefits and concerns about fundholding were debated.

AIM

A study was undertaken to compare process and outcome of care in patients with different levels of physical, social and psychological need in 1990 and 1992 in six fundholding groups in Scotland.

METHOD

Patients aged 16 years and over consulting with a range of marker conditions in 1990 and 1992 completed a pre-consultation health status questionnaire asking about physical, social and psychological problems, and a postconsultation satisfaction/enablement questionnaire asking about their ability to cope, and understand their illness. Main outcome measures were consultation length and satisfaction/enablement score.

RESULTS

Of patients attending in the study period, 39% consulted for one or more marker condition. The proportion of patients reporting social problems rose between 1990 and 1992 for 11 out of 12 conditions. Overall, consultation lengths remained constant. Patients wanting to discuss social problems had significantly longer consultations than those reporting no social problems or problems they did not wish to discuss. The proportion of patients expressing enablement dropped for eight conditions and rose for four between 1990 and 1992. The decrease in the proportion expressing enablement remained after controlling for the rise in the percentage reporting social problems. Patients who had social problems they did not wish to discuss but a general health questionnaire score of five or more were the group reporting lowest enablement. Significantly more patients with pain, skin problems and digestive problems reported social problems and significantly fewer of them reported enablement in 1992 compared with 1990. Patients with diabetes, angina, chronic bronchitis and problems seeing fared relatively well over the study period. Some patients with psychosocial problems fared poorly (they had relatively short consultations and were unlikely to express an ability to cope/understand their illness).

CONCLUSION

The issue of whether benefits to some patient groups from recent health service changes may be matched by disadvantage to other groups, for example those with clinical problems with no financial incentive to provide pro-active care or with psychosocial difficulties, is discussed.

Purchaser/provider separation and managed competition: reform options for Australia's health system

A purchaser/provider separation and managed competition have been recommended as options for reform of Australia's health system. This paper presents the theoretical basis and supposed advantages of each model. The introduction of the purchaser/provider separation in the United Kingdom and New Zealand is described, as are the proposals for implementation of managed competition in the United States and the Netherlands. The potential for either model to deliver its promised benefits is critically evaluated in the light of existing evidence. As yet neither model can command unqualified support but both are worthy of further consideration.

Evaluating care of patients reporting pain in fundholding practices

OBJECTIVE

To compare quality of care between 1990 and 1992 in patients with self diagnosed joint pain.

DESIGN

Questionnaire and record based study.

SUBJECTS

Patients identified at consecutive consultations during two weeks in 1990, 1991, and 1992.

SETTING

Six practice groups in pilot fundholding scheme in Scotland.

MAIN OUTCOME MEASURES

Length of consultation; numbers referred or investigated or prescribed drugs; responses to questions about enablement and satisfaction.

RESULTS

About 15% of patients consulted with joint pain each year. 25% (316) of them had social problems in 1990 and 37% (370) in 1992; about a fifth wanted to discuss their social problems. Social problems were associated with a raised general health questionnaire score. The mean length of consultation for patients with pain was 7.6 min in 1990 and 7.7 min in 1992. Patients wishing to discuss social problems received longer consultations (8.5 min 1990; 10.4 min 1992); but other patients with social problems received shorter consultations (7.4 min; 7.2 min). The level of prescribing was stable but the proportion of patients having investigations or attending hospital fell significantly from 1990 to 1992 (31% to 24%; 31% to 13% respectively). Fewer patients responded "much better" to six questions about enablement in 1992 than in 1990. Enablement was better after longer than shorter consultations for patients with social problems.

CONCLUSIONS

Quality of care for patients with pain has been broadly maintained in terms of consultation times. The effects of lower rates of investigation and referral need to be investigated further.

Can there be fair funding for fundholding practices?

Most regional health authorities set budgets for fundholding practices according to the amount of care used by the practice population. This article explains why this funding method can only lead to an inequitable allocation of resources between fundholding and non-fundholding practices. Using the experience of North West Thames region, the efforts made to make funding fairer are discussed. The steps that health authorities could take to investigate and reduce the problem are also outlined. In the absence of a capitation formula for funding fundholding practices, the paper suggests that health authorities should do much more to investigate the amount of money they spend on non-fundholding practices. Regions could develop and use other methods to set budgets rather than rely on activity recorded by practices. Regions and the Department of Health should resolve urgently if and how far the budgets for fundholders should be compensated for increases in provider prices.

Fundholding in Northern Region: practice managers' views

Describes the views of practice managers in 30 fundholding practices in the Northern Region concerning their role in the scheme. A self-completion questionnaire was mailed to practice managers and general practitioners containing questions designed to elicit their views about changes in relationships inside and outside the practice; their level of involvement in various aspects of fundholding; and the costs and benefits of the scheme. A total of 30 first-, second-, and third-wave fundholding practices in the Northern Region, June 1993 were involved. Replies were received from 22 practice managers (73 per cent) and 83 general practitioners (49 per cent). Concludes that although fundholding has increased the nature and volume of the workload of practice managers, these changes do not appear to be causing any tensions between managers and clinicians. At the moment fundholding extends the support role of practice managers and does not alter existing authority relations in practices.

Towards better practice management: a national survey of Scottish general practice management

Surveys a 50 per cent sample of Scottish practices (stratified by health board area), concerning whether they had a practice manager and who had responsibility for practice management tasks. The overall response rate was 73 per cent, with 63 per cent of responding practices employed a practice manager. Reports the findings from practices employing a manager, and reveals marked variations in levels of managers pay and responsibility. The development of practice management structures varied with only 85 per cent of practices holding regular practice management meetings. The results suggest that practices which previously coped without a manager have recognized the need for one as the complexity of practice administration increases and that the traditional career path of managers involving internal promotion is changing.

General practice fundholding: observations on prescribing patterns and costs using the defined daily dose method

OBJECTIVE

To compare prescribing patterns between a group of fundholding practices and a group of non-fundholding practices in north east Scotland using a method which provides more accurate statements about volumes prescribed than standard NHS statistics.

DESIGN

The pharmacy practice division of the National Health Service in Scotland provided data for selected British National Formulary sections over two years. Each prescription issued was converted using the World Health Organisation "defined daily dose" mechanism.

SETTING

Six fundholding groups (nine practices) in Grampian and Tayside regions and six non-fundholding practices in Grampian.

RESULTS

During the past two years both fundholding and control practices reduced the volume of their prescribing for the classes of drug analysed. The unit costs of drugs in some classes, however, rose substantially, contributing to higher costs per patient. The unit costs rose more in the control practices (24%) than in the fundholding practices (11% in Tayside, 16% in Grampian).

CONCLUSION

The use of defined daily doses helped identify cost and volume trends in specific areas of prescribing in fundholding and control practices. The basis on which funds are set needs improving, and defined daily doses may prove useful for setting volume targets within drug classes for all practices, whether fundholding or not.