NHS performance schemes having little impact, says report

November 28, 2012, University of Nottingham

Many of the controversial incentive schemes aimed at improving quality of service in the NHS may not be working as intended, a major new study has warned.

According to a report produced for the Department of Health by Nottingham University Business School, a number of so-called Best Practice Tariffs have had little or no impact on performance or standards.

Researchers did find evidence of some initiatives having a positive effect—in one case reporting 'significant' improvements—but said the extent was often limited. Some schemes also risked inviting 'unforeseen consequences', including hospitals basing certain on how much money they might earn.

Professor Ruth McDonald, who led the study, said the findings highlighted the need to devise and target such initiatives more carefully.

'Damp squib'

"The overall message is that BPTs can be used to incentivise hospitals but there's a lot of room for improvement," said Professor McDonald.

"In some respects these policies have proved a damp squib. In many cases, despite all of the , providers simply didn't leap to improve their services. Of course, there's an argument that the provision of decent care shouldn't need incentivising in the first place. Some critics even regard these schemes as ''.

"Even so, the fact is that some hospitals are still providing sub-optimal care and, in spite of these schemes, the benefits for their patients have yet to materialise."

The research, carried out in collaboration with the University of Manchester's Institute for , looked at four BPT initiatives.

The first of their kind in this country, they were introduced in April 2010 in an effort to improve performance in selected high-volume clinical treatments in the NHS.

Quality of care was assessed by comparing Hospital Episode Statistics data for the three financial years prior to their introduction to the first financial year afterwards.

Perverse incentives

A scheme to speed up gallbladder operations was found to have resulted in the number of patients treated on a "day case" basis rising by seven percentage points. But some senior employees interviewed for the study were critical of the concept, with one claiming it rewarded 'kicking patients out rather than letting them sleep'.

Another said: "If you don't do the procedure in the morning list you're not going to get Best Practice for it, because they need to stay eight hours after the procedure. If they have the operation at four in the afternoon we're not going to let them out at midnight. You don't want to just push people out of hospital as fast as possible."

Concerns were also raised that BPTs for stroke care and hip surgery could give rise to 'perverse incentives' that might leave some patients facing longer waiting times.

One physician involved in the stroke scheme—for which no evidence of impact was found—described how the prospect of extra income might influence decisions.

He told researchers: "You've got a patient who comes in at 8.30 today. I need to get their CT [scan] done by 8.29 tomorrow, but I can't. Then another patient comes in. Now I've got one slot available. Whose CT do you think I'll do – the one where I can earn £343 for the Trust, not the poor chap who's missed by a few minutes?"

In spite of similar concerns about unintended consequences, the study reported 'significant process quality and outcomes gains' for the hip-operation scheme.

Effort-reward balance

But an initiative intended to improve cataract treatments was largely shunned because the associated bureaucratic demands were considered too complicated.

Professor McDonald, a Professor of Healthcare Innovation and Learning, said the study showed many hospitals were slow to take up and prioritise BPT schemes.

She added: "It's important to recognise that these kinds of schemes are by no means confined to the NHS. Similar ideas are being implemented all around the world. Inevitably, the question that's most often asked is: 'Do they work?' But that's the wrong question, because it fails to acknowledge that these initiatives are all different.

"What we need to do, as we have here, is look at the features of individual schemes and assess the impact in each case to determine how well they function.

"As the Department of Health appreciates, this sort of independent evaluation is vital if we want to learn lessons about particular initiatives and approaches in general."

The report recommends future BPT programmes should target high-volume treatments for which standards in performance clearly vary across the country. It also says treatments for which existing data collection systems, quality initiatives and evidence-based standards are already in place should be given priority.

Professor McDonald said: "Going forward, it's important to focus BPTs on areas where efforts will be outweighed by rewards in terms of patient benefits."

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