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Financial Incentives for Primary Care Physicians

In 2000, the U.K.'s 50-year-old National Health Service embarked on a 10-year, multibillion-pound plan to overhaul the system. Its aims are to create financial incentives for primary care physicians to better their care and for surgeons to reduce waiting times, as well as to give patients access to medical information and more provider choice. We asked Simon Stevens, a 1994–95 Harkness Fellow in Health Care Policy and Prime Minister Tony Blair's health policy adviser for the past seven years, about the NHS reforms and the challenges faced by health systems on both sides of the Atlantic. In May 2004, Stevens left government to become president of UnitedHealth Group's European division, which develops tools to improve public health systems.

Earlier this year, the U.K. implemented a new contract for family physicians, with new quality indicators and financial incentives to improve care. What signs of progress are you looking for as this agreement takes effect?

Simon Stevens: This is probably the world's largest pay-for-performance experiment, with GPs able to earn around a third more in return for improving the quality of their clinical practice as measured on an evidence-based scorecard.The first stage will be GPs matching their current performance against this quality framework. After the first year, we'll get a sense of the extent to which people have improved positions, but I think it probably will be 18 months to two years before we'll be able to measure change at the overall system level. To actually make good on the incentives, GPs will need to put in place either new infrastructure in terms of doctors and nurses or redirect the efforts of people already in the system.

What's the first thing that you want to see the new IT infrastructure do?

Stevens: England is now installing electronic health records covering the whole population. We decided this needed to be a national procurement rather than being left to individual providers. So what the IT investment is buying for the NHS as a whole is the ability to network primary care and hospitals, test results, and so on.The first thing patients will notice is that they'll be able to schedule all doctor appointments electronically. There's also something called the HealthSpace section of your electronic health record that you can access online and input text into. And something called NHS Direct, which gives patients access to consumer-friendly and doctor-friendly versions of what the medical evidence says constitutes best treatment for a range of conditions.

U.S. health professionals and others are closely watching the NHS effort. What do you hope to show them?

Stevens: IT contracts have gone to a variety of international and U.S. companies. And if they can demonstrate proof-of-concept in England, that provides an important tool for them to sell elsewhere. It also allows us to test the payback from IT. We want to think about using the data sets we've got for population-based disease management and case management, and in doing so draw lessons from what some of the big managed care plans have been able to pursue.

It is very important for the NHS to reduce waiting times, a longstanding concern. How will that be done?

Stevens: We basically want to eliminate waits as an issue and we're doing so by expanding the supply of surgeons and giving consumers more choice. We're bringing in international operators to provide surgery on contract to the NHS.That has increased capacity and introduced a bit of competitive challenge to the system.And we are giving patients explicit choice over where they get routine surgery.

In the U.S., some physicians see the Internet as a threat because it gives patients more access to medical information. Is that an issue in the U.K.?

Stevens: It's too early to say.Type 'breast cancer' and Google offers you 5.7 million links. We know there's variability with quality of information out there, but we can make sure there is good information for patients who want it. But faced with this cognitive overload, many patients will need more, not less, hand-holding. And so that's what we're doing with this NHS Direct Web site. It's what we've been doing with the appraisals that the National Institute of Clinical Excellence [NICE] has been publishing. The extent to which we can incorporate these elements into chronic disease management, patient self-help skills, and so on is something we want to explore.

Fall 2004


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