A previous attempt to provide financial incentives for high-quality care in the mid-1980s, named ‘Good Practice Allowance’, was rejected by the general practitioners profession.
At that time, there was little acceptance of the finding that wide variations existed in the practice of medicine, or that such variation might have a negative effect on patient care
55.
Part of the reason that doctors rejected the Good Practice Allowance in the mid-1980s was that they rejected the assumption that quality could be measured. In addition, there was a substantial degree of professional protectionism that took the form of denying the existence of poor practice. During the 1990s evidence-based medicine was introduced.
Health professionals gradually accepted that there were differences in performance in the delivery of healthcare and that there were justifiable limits to individual freedom in the clinical setting. This was also the decade when researchers in health care demonstrated that there were widespread variations in healthcare delivery and that many patients were receiving care that fell short of what was considered good practice.
The effect of these developments was that it became increasingly possible both to define high-quality care and to provide methods that could be used to measure some aspects of the quality of care. The change in the culture of the profession that occurred during this decade in the UK was enormous 55. The last piece missing was the political will to implement the proposed changes. To tie a substantial proportion of physicians’
income to the quality of the care would produce winners and losers. However, the British Medical Association was unwilling to accept a change in remuneration that would result in the loss of income for large numbers of its members. In 2000 the government of the United Kingdom decided to provide a substantial increase in health care funding.
This change came as a result of recognition of the serious underfunding of health care in the United Kingdom as compared with that of similar countries, and the publication of data suggesting poor outcomes for health care in the country.
Negotiations took place between the British Medical Association and the NHS, with the assistance of a small group of academic advisers. The academic advisers drew on published national guidelines for sources of evidence, such as those from specialist societies. The details of the new contract were voted on by general practitioners in June 2003. There was a 70 percent turnout, and 79 percent voted in favour.
Although this description of the implementation and communication process is relevant to the interpretation of the included UK studies, most authors do not specify the context of implementation and communication.
4.2.5.2 United States of America
Similar to all other characteristics and the P4Q intervention design, the process of implementation and communication is also very heterogeneous in the USA. Like in the UK, many USA studies do not report on this subject. The history of implementation, especially the level of involvement and support by healthcare providers, is rarely described. The studies that do report on this can be grouped into low and high implementation and communication support for P4Q programmes. Support is provided in one or more of the following ways:
• Involvement of healthcare providers/peers throughout the P4Q programme design process by regular meetings 189 , 197 , 205 , 206.
• Involvement of healthcare providers/peers to review and approve evidence based guidelines as a basis for the P4Q programme 184, use of a multidisciplinary task force to identify evidence based practice and usable indicators 171 , 189 , 193.
• Involvement of healthcare providers/peers in the continuous updating process of the programme 205 , 206.
• Involvement of patients, office staff, educators, etc. 190.
• Clear leadership support 175 , 197, coordination by central leadership 190, directors and administrators invited to a project launch meeting 196.
• Support of similar involvement in the care improvement activities 190.
• Use of a small core work group and later refinement by the larger development team 190.
• The contact strategy:
o Feedback by mail or in person by a medical director 188, the use of multiple individual mailings 183, the use of letters and a brochure 184, notification in monthly bulletin 197 , 201 , 206 , 220.
o The use of formal presentations at standing meetings 197.
o Face to face feedback 210, personal communication 201, visit by a project representative offered to each intervention site 196.
o Annual manual provided with an executive summary, full description of the programme, answers to commonly asked questions 197 , 206.
o Provision of technical specifications for each measure 197, transparency of the methods used to determine performance rates and translation into a financial incentive amount via a public website 206.
• The use of interviews or surveys to check awareness of the programme and to assess acceptability 178 , 180 , 184 , 195, to assess satisfaction 206.
• The use of interviews or surveys to check measurement activities and how the data are used to maintain or improve the quality of care 210, reverse feedback about local guideline implementation efforts 197.
• The use of interviews or surveys to identify barriers impeding target attainment 182.
• The use of focus groups for similar purposes 222.
• The use of constant reminders of measures and targets, directly integrated into daily practice 222.
• The presentation of further improvement recommendations towards the participants 210, the use of suggestions on how to spend earned incentive payments 201.
• Tools and resources provided to support quality improvement, directed at directors and quality improvement teams 175.
Whereas the level of awareness of the programme was acceptable in some studies 180, a low level was found in other studies 183 , 184. One study reports a general misunderstanding by participants of contra indications which could be used to exclude patients 181. Another study identified an initial reaction of suspicion and distrust, disbelieve, being surprised by low baseline scores, a confrontation with poor documentation, which stimulated protocol development, outreach calls, enrolment in disease management programmes, new monitoring and follow-up assignments to staff, and the beginning of utilization of other not incentivized checklists 222.
A number of studies report that P4Q programme participation was of a voluntary nature 44 , 69 , 174 , 175 , 176 , 195 , 205 , 206 , 211. Other studies do not specify the mandatory versus voluntary design option. On the basis of the complete programme reporting it can sometimes be assumed that participation was obligatory. However, this assumption should be treated with caution when reviewing results.
4.2.5.3 Australia, Germany, Italy, and Spain
One Australian study states that the attitudes among participants have generally been positive, with high degrees of compliance and cooperation 213. The second Australian study makes use of a survey to identify barriers and reasons for not accomplishing targets 214.
No information on implementation and communication was provided in the German study 216.
In the Italian study, work plans and targets were set by regional health authorities 217, without further specifications on implementation and communication.
The Spanish study surveyed the level of job satisfaction of participants and their quality of professional life, using standardized instruments 218. The results are included in the effects reporting section 4.3.1 (see page 54).
Key points on implementation and communication United Kingdom
• A first attempt to implement a P4Q programme in the mid-1980’s, was rejected by the professionals, partly because physicians rejected the assumption that quality could be measured. With the introduction of evidence based medicine, the health culture changed.
• In a second attempt to implement a P4Q programme, which leaded to the implementation of QOF in 2004, the government decided to provide a substantial increase in health care funding and negotiations took place between government and professionals with the assistance of a small group of academic drivers. Participation in the QOF programme is voluntary.
USA
• Implementation and communication support is provided in one or more ways, depending on the programme. They include mainly involvement of providers/peers, involvement of patients, office staff and educators,
leadership support or the use of a small core work group. In addition there has been made use of interviews or surveys, focus groups, reminders and presentations to communicate and implement the programme. The level of awareness of the programme varied between programmes as well as the acceptance. Participation was generally voluntary, although it can be assumed that some programmes are obligatory.
Australia, Germany, Italy and Spain
• Communication and implementation differed according to the P4Q
programme. In some countries a multidisciplinary committee developed the programme, in other countries the targets and work plans were set by the (local) government.