Incentives and inducements

HEALTH services across the UK face huge pressure to make future efficiency savings in the provision of care – some £15-20 billion being the target. Initiatives such as the Quality, Innovation, Productivity and Prevention (QIPP) programme incorporate various national work streams designed to support the NHS in improving care and lowering costs.

In late 2012 the BMA highlighted a number of primary care incentive schemes designed to achieve QIPP objectives through a reduction in referrals or prescribing activity. The GPC expressed concern that some schemes "reward arbitrary reductions in clinical activity without evidence that this is in the best clinical interests of individual patients". Some of the schemes also made no stipulation that the savings achieved should be reinvested in improved patient care.

Among examples cited by the BMA was a scheme rewarding practices in the top 25 per cent of outpatient referrers to reduce their referral rate per 1,000 population by 10 per cent or to the 75th quartile where clinically appropriate. Practices were to be paid £1 per head with no restriction on how money was spent and also no assessment of whether the referral reduction was achieved through clinically appropriate means.

Concern over some incentive schemes no doubt prompted the GMC to address the issue in its own explanatory guidance published last year in support of the revised Good Medical Practice. Paragraphs 78-80 of GMP state: "You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients... You must not ask for or accept – from patients, colleagues or others – any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients. You must not offer these inducements."

In supplementary guidance on Financial and commerical arrangements and conflicts of interest (2013) the GMC addresses the specific issue of target payments and incentives in prescribing. It states: "Health service financial incentives and similar schemes to improve the cost-effective use of medicines have a legitimate role to play in helping to make good use of available resources. Such schemes can also benefit the wider community of patients. But you must consider the safety and needs of the individual patient for whom you prescribe."

The GMC further states that doctors should consider the benefits and risks to the patient whenever considering a change in medicine for reasons of cost. It cites one particular risk that a patient’s adherence to a medicine could be harmed by frequent switching.

The GMC advises: "You should follow clinical guidelines and raise concerns if you have good reason to think that patient safety is or may be seriously compromised by financial incentives and similar schemes."

In regard to the most ubiquitous primary care incentive scheme – the Quality and Outcomes Framework – the GMC states: "Preventative health measures, such as immunisation of children and screening for cervical cancer, have clear benefits for both individual patients and society, as do health monitoring schemes such as those encouraged through the Quality and Outcomes Framework. Target payments are used to encourage general practitioners to increase the number of patients involved. Although you may wish to recommend treatments and invite patients to participate in assessments, you must not put pressure on patients to participate because of the financial benefits for you."

The BMA also offers advice on incentive schemes in its own guidance, Conflicts of interest in the new commissioning system: Doctors as providers, published in April 2013. It states that doctors should "satisfy themselves that any incentive scheme does not constitute an inducement that may affect, or be seen to affect, the way they treat patients". Doctors should also satisfy themselves that any such scheme is based on clinical evidence and should raise concerns if they think patient safety may be compromised.

In addition, incentive schemes must be of benefit to a community of patients or to individual patients but should not encourage a uniform or blanket approach to all patients with the same condition. Doctors should also ensure that payments arising from the scheme are used to improve patient services.

ACTION: MDDUS urges any doctor with concerns about a proposed incentive scheme to seek advice from their LMC or health authority or contact an MDDUS adviser to discuss these concerns.