I have three suggestions, all of which relate to primary care.

  1.  Additional financial incentives for GPs to re-locate in deprived areas with a relatively low number of GPs per head of population. Current incentives (eg LISI payments) have failed to achieve geographical equity of access to GP services, as deprived areas remain demonstrably under-doctored compared with affluent areas. This geographical inequality is associated with, and a probable cause of, well-documented socio-economic inequalities in the use of hospital services such as hip replacement and revascularisation. GPs have always had powerful personal and professional incentives to locate in affluent areas—ie, to put it rather crudely, a nicer home environment and an easier caseload. The QoF scheme adds an additional perverse financial incentive, since it is easier to score highly on any given target for treatment "quality" with relatively advantaged patients who actively request the latest treatment and comply with it. These perverse incentives need to be countered if this fundamental, long-standing and persisting geographical inequality of access to health care is to be remedied.

  2.  New QoF incentives to encourage case finding of disadvantaged individuals for cost-effective QoF interventions such as statins and smoking cessation therapy. Under current QoF rules, GPs have perverse incentives not to case find disadvantaged individuals. This is because (i) case finding is labour-intensive, (ii) disadvantaged individuals often cost more to treat due to co-morbidity, and (iii) meeting any given target for treatment "quality" is harder to achieve due to non-compliance issues. Without incentives to case find, disadvantaged individuals will continue to have a relatively low take-up of life-prolonging preventive health care interventions. These new incentives could take the form of a payment to the GP practice for each new case diagnosed among their disadvantaged patients, to compensate for case finding effort. More radically, the new incentives could also include a conditional payment to the disadvantaged individual in question to encourage compliance (eg using the existing LISI scheme to identify an individual as "disadvantaged"). However, any patient compliance incentives would need careful design and piloting, as it is easier to monitor compliance with some treatments (eg statins) than others (eg smoking cessation)—and, unfortunately, the areas where compliance is hardest to monitor tend to be areas where monitoring is most needed. Nevertheless, with imagination some sensible pilots could be designed.

  3.  Re-design QoF incentives to improve cost-effectiveness—ie more health gain per pound spent—in the following three ways:

(a).  Add selected new indicators with low expected cost per QALY (ie high health gain per pound spent) compared with existing indicators.

(b).  Reduce payments to zero while retaining current data collection requirements for selected existing indicators with high expected cost per QALY. The requirement to maintain current data collection requirements is crucial since (i) it maintains a "peer comparison" incentive to continue performing well (some studies suggest that "peer comparison" incentives can be powerful, independently of financial incentives) and (ii) it allows gathering of much needed evidence to inform the design of future incentive schemes—are quality gains maintained once financial incentives are withdrawn?

(c).  Strengthen incentives for additional quality improvements, for the same incentive payment expenditure, by abolishing the upper payment threshold and reducing payments per point to achieve cost-neutrality. Announce the payment per point AFTER the quality scores are in and calculations have been made, to achieve cost-neutrality.

Richard Cookson

University of York

January 2007