Associate Health Economist
J Quigley MSc
M Singh MSc
ICON Health Economics, Oxford, UK
S Keeping MSc
Health Economics Analyst
Sanofi Pasteur MSD, Maidenhead, UK
R Pitman PhD
Lead Health Economist
ICON Health Economics, Oxford, UK
S Carroll MSc FRSPH
Sanofi Pasteur MSD, Maidenhead, UK
Received date: 14 February 2014; Accepted date: 2 April 2014
Objective This paper aims to examine the role of local enhanced services (LES) as a financial incentive in improving clinical and process outcomes in primary care with a view to discussing their future in light of the Health and Social Care Act. Methods A literature review was conducted to identify LES commissioned in the UK in any disease area and to evaluate common themes relating to their impact on outcomes. The literature review consisted of two stages: an initial reference database search (MEDLINE, MEDLINE IN-PROCESS and EMBASE) and a more general internet search. The internet search used free text augmented by a targeted search of key health organisations’ websites.Data were extracted fromthe LES to provide information on the background and context of the LES before going on to describe the incentive structure, health and economic outcomes and limitations of the LES. Results Although a number of LES were identified in the online search, only 14 reported any data on outcomes. These LES programmes related to 10 different disease areas, with cancer, alcohol dependence and chronic obstructive pulmonary disease (COPD) being the most common health needs. Three common factors between the selected LES emerged that appear to influence the extent of the impact on local health or economic outcomes: (1) a national framework supporting the LES, (2) existing service provision, and (3) the size of the financial incentives. Conclusion The common themes emerging from the literature review suggest that, following the Health and Social Care Act 2012 and newly established national standards, given sufficient attention to planning service specifications, LES could continue to be important in reducing health inequalities and preparing poorly performing general practices for longer term changes directed at improving outcomes and standards in healthcare.
delivery of healthcare, health policy, health services research, primary healthcare
How this fits in with quality in primary care
What do we know?
Economic incentives have been central in primary care policy since 2004. Local enhanced services (LES) have formed part of a wider range of programmes designed to expand service coverage and meet health outcome targets. Following the Health and Social Care Act 2012, additional financial resources in national frameworks have been offered to general practitioners for achieving improvements in health indicators.
What does this paper add?
The literature on financial incentives in primary care has tended to focus on national programmes. This paper describes a targeted review undertaken to identify the different types of LES and their role in driving health and economic outcomes. The article discusses common factors that may have influenced LES outcomes and suggests that LES may play an important role in the new commissioning system in paving the way for a higher standard of care as a short-term catalyst for developing service provision pathways.
Economic incentives have been central to policy towards general practice since the General Medical Services (GMS) contract of 2004, with the aim of incentivising providers to expand service coverage and meet health outcome targets in high-priority clinical areas. The Health and Social Care Act (HSCA) 2012 overhauled the structure of primary care commissioning and placed clinicians at the forefront of commissioning in the National Health Service (NHS). In addition to the minimum practice income guarantee, the GMS contract continues to offer general practitioners (GPs) additional financial resources for participation in the Quality and Outcomes Framework (QOF), direct enhanced services (DES) and local enhanced services (LES). Since April 2013, this has been supplemented by the Quality Premium, which awards payments for achieving improvements in health indicators based on the NHS Outcomes Framework.
The QOF is a national incentive scheme commis-sioned by NHS England through the GMS contract, consisting of payments for meeting target thresholds. DES are nationally specified schemes, also commis-sioned by NHS England, that aim to enhance the quality of the essential, additional or out-of-hours services set out in the GMS contract; or to provide such services that are not currently included in the GMS. Unlike the QOF, DES provision is mandatory and non-participation is penalised by reductions in GPs’ global sum payment.
LES, commissioned for the same purpose as DES, are determined in response to local health priorities in the jurisdiction of the local commissioning body. Prior to the HSCA 2012, primary care trusts (PCTs) commissioned LES from any appropriate service pro-vider in the local community and specified the pay-ment structure for fulfilment of LES goals. The HSCA changed the structure of primary care commissioning and placed NHS England, a newly established arm’s length non-departmental body, at the centre of the commissioning of NHS services. NHS England has the ability to commission LES, but may delegate this responsibility to clinical commissioning groups (CCGs). PCTs and CCGs jointly managed LES in the transitional period following the introduction of the HSCA.
Payments for successful outcomes are common to most LES specifications, although LES may differ in the number of outcomes assessed. Some LES may entail an initial start-up payment or a closing fee.[6–10] Where the aims of an LES overlap with national directives, an LES could help a GP practice prepare for longer term changes required to meet national targets and to meet existing coverage gaps. However, LES payments may be regarded as a permanent pay-ment for an activity that may have been undertaken regardless of an incentive scheme and LES have been criticised for their complex incentive arrangements.
The literature on financial incentives for perform-ance in primary care has tended to focus more on national frameworks than on local services. The aim of this paper is to examine the role of LES as a financial incentive in improving clinical and process-related outcomes in primary care with a view to discussing their role following the HSCA 2012 reforms. The paper describes a targeted literature review consisting of a bibliographic database search and online grey literature search undertaken to identify the different types of LES that have been commissioned in the UK. The article outlines the methods used to search and identify LES programmes and discusses the common themes in their pre-HSCA 2012 role in driving health and/or economic outcomes and how this could affect their future role in the new commissioning landscape.
The methods below describe the searches for docu-ments that met the following inclusion criteria: relating to an LES or community based service commissioned for children or adults with any medical condition and including data on relevant LES outcomes, such as uptake rates, disease prevalence, economic outcomes, health outcomes and quality of life (QOL). All publi-cation types were considered and geography was restricted to the UK.
Searches were carried out in MEDLINE and MEDLINE IN-PROCESS and EMBASE using the Ovid SP1 service provider on 24 May 2013. Search strategies combined free text terms for all enhanced services and controlled vocabulary terms for primary care and physician incentives, and are presented in Table 1. A total of 459 abstracts were identified and were screened for relevance by an experienced re-viewer according to the eligibility criteria described above (Figure 1). Any queries about inclusion were discussed with a second reviewer. Where abstracts only met some of the eligibility criteria, the publi-cation was ordered for full paper review. The refer-ences of the three selected publications were searched to identify relevant LES publications.
Because there is a large amount of grey literature relating to commissioning in the NHS, a targeted search of online sources was undertaken to identify relevant information that was unlikely to be found in bibliographic databases. The targeted search was con-ducted between 29 May and 5 June 2013 on the websites of the local and national health organisations listed in Table 2. The search was undertaken in the transitional period as the HSCA 2012 came into effect. Few of the PCT websites searched were fully functional and some had been recently decommissioned. In such cases, an archived version of the website on the UK National Web Archive was searched for relevant LES documents. This search was supplemented by using free text terms based around LES disease areas and outcomes in Google to identify relevant publications (Table 1). LES-related documents were only included and extracted if outcomes of the LES were reported.
Information in selected LES publications on the author, publication year, disease area, commissioning organisation, year of introduction and aims were extracted to provide some background on the LES. The incentive structure, outcomes and limitations of the LES were also extracted to provide further infor-mation. These were then qualitatively synthesised to examine any common factors that influenced the outcome of an LES
A total of 14 selected LES programmes were identified and described in 14 publications. Of these 14 relevant documents, three were retrieved using the database search and 11 through the online search. The materials identified through the online search comprised seven reports published by the organisation commissioning the LES, two case studies, one letter and one slide deck. Of the seven retrieved reports, two reported the out-comes and payments of the same LES and one reported outcomes of three distinct LES.[11–13] The letter obtained in the online search described the same LES as one of the documents retrieved in the database search.[6,7]
The selected LES studies are presented in Table 3. The most common disease area for the extracted LES was cancer, with three LES (all cancer types, breast cancer and prostate cancer), followed by alcohol misuse and chronic obstructive pulmonary disease (COPD). In six of the LES, the aim was to build on a national policy in the disease area. Devereux built on an earlier DES for cancer, which provided baseline infor-mation and raised awareness of referral guidelines. Keep Well/Enhanced Data Group stated that the purpose of the three LES for diabetes, stroke and coronary heart disease (CHD), respectively, was to extend GMS QOF into important health-related be-haviour areas. Both LES for COPD were supported by QOF targets for diagnosing and managing the dis-ease.[6–8] Falzon used data on COPD prevalence from the national QOF database as a measure of locally observed diagnoses and reported that an objective of the LES was to ensure that practices provided a quality of care in line with the National Institute of Health and Care Excellence (NICE) guidelines.
Table 4 presents the incentive structure, outcomes and limitations of the identified LES programmes. The type of payments made or a description of the incen-tive structure in place were extracted for eight out of 14 LES, although the RCGP publication did not state the specific amounts paid to GPs. Mookherjee did not report details of the incentive structure, although a description of payments made was found under a brief profile of the Lewisham LES on the Alcohol Learning Centre website.
Four of the eight LES incentive structures extracted entailed a retainer fee or start-up cost, varying from £600 to £2000.[6–10] Only two LES were reported to include a closing fee (£250 to £600) for concluding the service.[8,14] The two patient referral LES for cancer, Devereux and Wright, reported similar amounts paid per patient of £75 for each completed Cancer Patient Referral Analysis, and £80 per patient trans-ferred from a urology department to a general practice for follow-up.
The COPD LES differed in the number and size of payments and the eligibility indicators for payments to be made. Practices participating in the LES in Kensington and Chelsea received up to £10 per patient screened and £80 per patient if a full COPD review was undertaken. For new patients screened and diagnosed with COPD, only the £80 fee was paid.[6,7] By contrast, practices in Islington had six COPD management indicators to meet with payments varying from £20 per case-finding using spirometry to £50 for improved management of each patient with severe COPD, in addition to lump sum payments of £600 for start-up and audit completion.
Thirteen LES were associated with some improve-ment in outcomes, seven of which were related to clinical outcomes, such as increased diagnoses of COPD, dementia and sexually transmitted infections (STIs) and improvements in health inequalities.[6,8,9,13,17] .The COPD LES in Kensington and Chelsea was estimated to be associated with an increased preva-lence of COPD diagnoses in 2011 to 1.2%, compared with a projected 2011 prevalence without an LES of 0.9% based on pre-LES trends in Kensington and Chelsea. The LES in Islington was estimated to have reduced the gap between observed and modelled local COPD prevalence in 2010/11 by 13%. By contrast, the LES for cancer-related referrals and for prostate cancer provide examples of process-related outcomes as they were believed to have made some improve-ments in existing processes of referrals and follow-up,[14,16] and the LES for breast cancer screening identified some baseline data for the Gypsy Traveller community.
Outcomes information was poorly reported for the two LES on alcohol misuse, with a lack of baseline information in a questionnaire completed by GPs on awareness of local alcohol services in Lewisham, and only participation data reported in Wandsworth. The authors believed that practice participation in Wandsworth was low because GPs did not see the payments offered as a suffcient incentive to identify and refer patients, particularly when improvements were thought to be required in the service provision pathway for specialist alcohol services.
Low uptake among smokers who had relapsed during past NHS quit attempts was seen as a limiting factor in the smoking cessation LES in NHS Greater Glasgow and Clyde. Despite the apparent improve-ment in smokers’ relapse rates in the enhanced service, only 421 patients participated in the enhanced service compared with 9621 patients in the basic service.
An STI LES in City and Hackney was believed not to have had a significant impact on testing in 2008 despite an eightfold difference in the number of positive chlamydia diagnoses per 1000 practice popu-lations between LES and non-LES-participating GPs. The authors suggested that the apparent success associated with the LES had likely resulted from inequalities in service provision between practices that provided the LES and those that did not that pre-dated the introduction of the LES. While authors did not believe that the LES itself had a major impact on increasing STI diagnoses, they did suggest that the service might have been useful in supporting GPs who wished to increase testing.
On reviewing the outcomes data of the selected studies, common themes emerged that may explain the success or failure of an LES. First, having a national framework already in place may have positive spillover effects for an LES. At the time that the COPD LES in Kensington and Chelsea was initiated, the National Service Framework for COPD and a QOF indicator for COPD had placed the disease high on the NHS agenda. As national targets for COPD management were already in place, improvements in COPD diag-noses through spirometry testing in the LES may have been less diffcult to implement. While the existence of a national framework could suggest that the condition was of particular clinical importance, thereby explaining increased LES activity, the combination of the finan-cial incentives may provide greater motivation for service provision than if no national framework were in place.
Second, existing conditions of service provision may affect both the clinical and process-related out-comes of an LES. The National Dementia Strategy formulated action plans to prioritise and to improve diagnosis and care in hospitals and care homes prior to the introduction of the LES scheme, possibly encour-aging the LES’s outcomes of early diagnosis and referral through supporting the subsequent treatment of referred patients. By contrast, Devereux stated that 28% of practices participating in the cancer referral LES believed that the LES did not represent good value for money as these practices had already been referring patients appropriately.
Third, the size of the financial incentives may also play a major role in positively influencing an LES, particularly when other factors such as existing service provision are taken into account. The payments offered to GPs in Wandsworth for providing an LES for alcohol misuse were not considered to be enough to participate and increase diagnoses of alcohol misuse disorders without improved treatment pathways and reduced waiting times for entry into specialist alcohol services. The LES resulted in a low uptake rate of six of 49 practices and insuffcient data gathered on absti-nence and completion rates within participating prac-tices. The 2008 LES to enhance GP care in care homes achieved a successful process-related outcome in re-ducing the overreliance of care homes on emergency services for crisis management. Although the size of the payments is not reported, incentivising GPs to visit care homes more regularly based on additional pay-ments per number and type of bed covered seemingly influenced care home staff ’s actions in crisis manage-ment, as the number of emergency admissions, fol-lowing LES introduction, fell from the previous year.
Overall, although limited, the evidence from the studies identified suggests that the success of an LES was conditional more on GPs’ willingness to partici-pate than on patients’, and that GPs’ inclination to participate in an LES was motivated by the existing treatment delivery hierarchy necessary to support LES implementation as well as financial incentives.
Financial incentives in healthcare have been criti-cised for crowding out clinicians’ intrinsic motiv-ations. The HSCA has placed GPs at the forefront of deciding the allocation of healthcare resources and commissioning. These reforms were enacted in re-sponse to: (1) rising demand and treatment costs, (2) the need to improve health outcomes, and (3) austerity in public finances. Whether LES have a foothold in the new commissioning structure remains to be seen.
One contributing factor to higher treatment costs is the increasing prevalence of long-term conditions in an aging population. The LES programmes identified in the review related to chronic conditions and entailed screening or periodic monitoring; suggesting that preventive LES could play a role in averting problems associated with long-term conditions and mitigate rising treatment costs. However, in an inter-view of 508 PCT employees, 18% of respondents doubted whether LES prioritise improvements in QOL and health outcomes for patients and believed that LES focused instead on rewarding activity.
Overlap between similar goals in the same disease area under an LES and a national scheme has been criticised as paying twice for almost identical health outcomes. However, a counterexample to this criti-cism is the Influenza and Pneumococcal Immunis-ation Scheme DES, which targets certain clinical risk groups with chronic conditions, but omits the follow-ing at-risk groups recommended by the Department of Health: healthcare workers, pregnant women, patients with chronic liver disease, and patients outside Wales with chronic neurological disease. A LES for influenza immunisation could be implemented to target these groups and complete any existing coverage gaps.
The increased presence of clinicians in primary care commissioning could mean that incentivising prac-tices to provide or enhance services outside the GMS contract could rely more on appealing to clinicians’ intrinsic motivation rather than the monetary-based incentive arrangements of an LES. As the GPs involved in CCG commissioning have less time to spend in clinical practice, there could be an increase in the commissioning of LES from other appropriate service providers, such as pharmacists. Alternatively, clin-icians may continue to commission LES to enable practices that are otherwise constrained by resources to provide the required services, although this could lead to a persistence of inequalities in healthcare if some GPs, for example in more deprived areas, are unable to invest time themselves in advocating the commissioning of LES within a CCG.
Since 2004, the QOF has incentivised practices to participate voluntarily in expanding the coverage of certain services for clinical risk groups in return for additional payments. However, in 2013–14, the total number of QOF points awarded for meeting targets fell from 1000 points in the previous year to 900 points. This may diminish motivation to extend coverage of healthcare services to clinical risk groups or even to participate in the QOF. Nonetheless, this may be offset by the universal introduction of a deduction from the global sum monthly payment if at least 150 QOF points are not achieved, which may improve service provision for clinical risk groups in practices who had previously opted not to participate in the QOF.
In addition, two frameworks were introduced in order to support the drive for improved outcomes in the NHS: the NHS Outcomes Framework and the Quality Premium. The NHS Outcomes Framework contains five health and social care domains which will be used by the Secretary of State to hold NHS England to account for NHS quality and commissioning. Quality Premium payments reward CCGs for meeting four measures based on the NHS Outcomes Framework. The LES identified in the review fall under some of the domains of the NHS Outcomes Framework and Quality Premium measures, such as enhancing QOL of people with long-term conditions, reducing avoid-able emergency admissions and preventing people from dying prematurely.[3,23]
LES may continue to have a role in future com-missioning in providing resources to improve health outcomes in practices that are lagging behind nationally specified standards and in doing so, improve in-equality in health outcomes. However, this review has identified that existing levels of service provision can influence the success of an LES. Capacity con-straints in the rest of the service provision pathway were noted in Marks and this is an issue that may affect poorly performing practices in particular. Whether this criticism could be counteracted by larger financial incentives is uncertain. That payments should be suffciently large to incentivise GPs may make LES more susceptible to budget cuts. Furthermore, as they are not part of the core GMS contract, CCGs and NHS England may find it easier to withdraw this type of service provision to make cost savings within an ever-tightening public budget.
Whether LES will continue to play a role in clinical commissioning remains to be seen, although the continuation of existing national incentives and the addition of new national specifications, i.e. the NHS Outcomes Framework, Quality Premium, and the mandatory achievement of 150 QOF points, suggest that an LES with similar aims in the same disease area may be successful and could be critical in ensuring that there are no gaps in coverage of at-risk groups. Given the on-going nature of the health reforms and the justifications cited above for their enactment, LES could play an important role as a short-term catalyst in developing the service provision pathway for a higher standard of care and improved health and economic outcomes.
The authors would like to acknowledge the assistance of Mark Sculpher and Nichola Naylor in reviewing this manuscript and the contributions of Andrew Lloyd, Dr Sarah Jarvis, Dr George Kassianos and Dr Douglas Fleming at the roundtable discussion preced-ing the initiation of the literature review. The authors also wish to acknowledge the reviewers, Viet-Hai Phung, John Ford and Nick Steel, for their time and comments on the manuscript.
This research received funding from Sanofi Pasteur MSD. The authors have not received any funding directly or indirectly from Sanofi Pasteur MSD in the subject matter or materials discussed in this manuscript.
Ethical review was not required.
Not commissioned; externally peer reviewed.
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