Exempting dissenting patients from pay for performance schemes: retrospective analysis of exception reporting in the UK Quality and Outcomes Framework
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2405 (Published 17 April 2012) Cite this as: BMJ 2012;344:e2405
- Tim Doran, clinical research fellow1,
- Evangelos Kontopantelis, research fellow1,
- Catherine Fullwood, research associate2,
- Helen Lester, professor of primary care3,
- Jose M Valderas, clinical lecturer4,
- Stephen Campbell, senior research fellow1
- 1Health Sciences Research Group-Primary Care, University of Manchester, Manchester M13 9PL, UK
- 2Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester
- 3School of Health and Population Sciences, University of Birmingham, Birmingham, UK
- 4NIHR School for Primary Care Research, Health Services and Policy Research Group, Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Correspondence to: T Doran tim.doran{at}manchester.ac.uk
- Accepted 6 March 2012
Abstract
Objective To examine the reasons why practices exempt patients from the UK Quality and Outcomes Framework pay for performance scheme (exception reporting) and to identify the characteristics of general practices associated with informed dissent.
Design Retrospective analysis.
Setting Data for 2008-9 extracted from the clinical computing systems of general practices in England.
Participants 8229 English family practices.
Main outcome measures Rates of exception reporting for 37 clinical quality indicators, associations of patient and general practice factors with exception rates, and financial gain for practices relating to their use of exception reporting.
Results The median rate of exception reporting was 2.7% (interquartile range 1.9-3.9%) overall and 0.44% (0.14-1.1%) for informed dissent, but variation in rates was wide between practices and across indicators. Common reasons for exception reporting were logistical (40.6% of exceptions), clinical contraindication (18.7%), and patient informed dissent (30.1%). Higher rates of informed dissent were associated with: higher numbers of registered patients, higher levels of local area deprivation, and failure of the practice to secure maximum remuneration in the previous year. Exception reporting increased the cost of the scheme by £30 844 500 (€36 877 700; $49 053 200) (£0.58 per patient), with two indicators accounting for a quarter of this additional cost.
Conclusions The provision to exception report enables practices to exempt dissenting patients without being financially penalised. Relatively few patients were excluded for informed dissent, however, suggesting that the incentivised activities were broadly acceptable to patients.
Footnotes
Contributors: TD and EK participated in the planning of the study, analysis and interpretation of data, drafting and editing the text, and had full access to all of the data in the study. TD takes responsibility for the integrity of the data and the accuracy of the data analysis. He had final responsibility for the decision to submit for publication. CF, HL, JMV, and SC participated in the planning of the study, analysis and interpretation of data, and editing the final text. SC had full access to all the data in the study. All authors have seen and approved the final version of the manuscript.
Funding: This study received no direct source of funding.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Not required.
Data sharing: No additional data available.
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