INCUMPLIR LA REGLA GENERAL NO GENERA MAYORES COSTOS

Productivity and effectiveness are terms that are used in myriad ways. A classical definition of productivity is simply the ratio of outputs to inputs, and is often defined in simple financial terms. However, in health care this definition is not sufficient–the simple measurement of financial outputs does not usually take account of the quality of care delivered. Productivity in health care should measure‘how much health for the pound, not how many events for the pound’.15_{Therefore, a definition often used within health is} ‘the ratio of outputs to inputs, adjusted for quality’.16_{(Reproduced from Applebyet al.}16_{© The King}’_{s Fund} 2010. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to copy and redistribute the work, provided the original work is properly cited. See: https://creativecommons.org/licenses/by-nc-nd/4.0/). However, the nature of this adjustment is a matter of debate: it is not generally possible to assess the financial effects of quality directly, as to do this would require assessment of the services’marginal contributions to social welfare,17_{and identifying and isolating these contributions would be difficult if not impossible (although,} in principle, identifying the financial inputs should be easier).

Although attempts have been made to measure quality-adjusted outputs directly (e.g. Dawsonet al.18 and Castelliet al.19_{), these have tended to focus on secondary care, and do not generally account for the} wide range of potential data, but instead rely on routinely collected outcome data. Quality can refer to a mixture of things, including health outcomes, safety and patient experience. Here, it is argued that, particularly for primary care, the full extent of quality cannot be measured without taking into account a broader set of indicators, for example the views of patients.20

INTRODUCTION AND BACKGROUND

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Given the importance of primary care and general practice within the NHS more widely, it is perhaps surprising that there have not been more attempts to provide a more specific definition and measurement of productivity–or other forms of performance, such as effectiveness–that can be applied at the practice level. There have, however, been various attempts to capture the performance of general practice for other, more specific, purposes.

The widest-known current method for assessing general practice outputs is the QOF. This sets payments to practices based on their activity against a number of indicators across two principal domains. Practices report on their performance on these indicators in accordance with clearly defined criteria; each indicator has a different weighting, so that the total QOF score is composed of a weighted sum of all the indicators together. Specifically, in 2017/18, there were 63 clinical indicators (across 19 specific clinical conditions or groupings of condition) and 12 public health indicators.21

Despite the growing demands of a larger population, more older people and more people with multiple chronic conditions requiring management in primary care, the share of NHS spending on general practice has fallen in recent years. There are plans to redress this problem, and in April 2016 NHS England announced a 5-year plan to increase investment in general practice.11_{The funds allocated to each practice each year} include a global sum calculated to adjust for workloads and features of the patient population (age, morbidity, mortality, population turnover), and pay for performance elements made up of the QOF and enhanced services, some of which may be determined locally. On the basis of these payment streams, in 2014–15 practices received a median of £105.79 (interquartile range £96.35–121.38) per patient. In recent work,22_{however, it has been shown that population factors related to health needs were, overall, poor} predictors of variations in adjusted total practice payments and in the payment component designed to compensate for workload.

The precise content has varied from year to year. Notably, all of the‘quality and productivity’indicators and the one‘patient experience’indicator from earlier years were discontinued from 2014/15 onwards, giving the impression that only clinical outcomes, rather than other areas of effectiveness and patient experience, are being prioritised. QOF has been criticised for many reasons, including being arbitrary in its setting of targets, being influenced by contractual negotiations, being subject to regular changes and creating tensions between patient-centred consulting and management.23,24_{These arguments will be} expanded in the next section, which reviews the literature on the topic. Other output measures, such as those used by the Office for National Statistics (ONS) and the National Institute for Health and Care Excellence (NICE), likewise do not cover all activity or focus on a different level (e.g. the NHS Outcomes Framework, which focuses on the CCG level).25

The importance of primary care quality is further indicated by the fact that the Care Quality Commission (CQC) now inspects general practices, including out-of-hours (OOH) services. These inspections ask the key questions about whether or not services are safe, effective, caring, responsive and well led. This brings together quality and safety, but does not directly address productivity, and leads to a broad-brush rating at one of four levels between‘inadequate’and‘outstanding’.26

Any comprehensive measure of general practice productivity or effectiveness would, however, need to consider the wide range of outcomes from primary care, including elements relating to public health and health improvement. In order to capture the range of outcomes, but also the differing importance of them, a model is needed that addresses both of these factors. The model used in this study does this. This approach, explored in greater depth in the following section, provides a method of capturing a range of different objectives and assigning them different weights, and is driven by the users on the ground: in this case, general practice staff and patients.27

Performance measurement: literature review