Impact of the introduction of fee for service payments on types of minor surgical procedures undertaken by general practitioners: observational study

Pockney, Peter; Primrose, John; Kinley, Helen; George, Steve; Lattimer, Valerie; Smith, Helen; Little, Paul; Lowy, Adam; Kneebone, Roger

doi:10.1093/pubmed/fdh152

Cited by 7 publications

(5 citation statements)

References 2 publications

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“…In our previous review, we also suggested that financial incentives introduced for GPs to conduct minor surgery in the early 1990s led to them carrying out operations for relatively trivial conditions that would not previously have been referred to hospital or where non-operative treatments were available, a conclusion supported by a more recent study. 202 A second set of studies assessed the impact of the QOF on hospital utilisation. [199][200][201]203 This pay-for-performance scheme did not (initially) have any incentives related to outpatient referrals but did provide incentives for chronic disease management that could have impacted on referrals.…”

Section: Scoping Review (Main Study)mentioning

confidence: 99%

Outpatient services and primary care: scoping review, substudies and international comparisons

Winpenny

Miani

Pitchforth

et al. 2016

Health Serv Deliv Res

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AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.

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Section: Scoping Review (Main Study)mentioning

confidence: 99%

Outpatient services and primary care: scoping review, substudies and international comparisons

Winpenny

Miani

Pitchforth

et al. 2016

Health Serv Deliv Res

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“…Thus, this study contends that remuneration structures in future contracts need to recognise how GPs can react to financial incentives rationally in a self-interested manner, as noted by Croxson et al (2001), Pockney et al (2004), Walley et al (2000) and Whynes et al (1999). However, these structures must also ensure that their underlying altruistic professional values and demonstrable behaviours are appropriately reflected (Hausman and Le Grand, 1999;Spoor and Munro, 2003;Young et al, 2012) and not adversely interfered with.…”

Section: Limitations and Implicationsmentioning

confidence: 96%

“…As evidence, Pockney et al (2004) identified GPs making extensive use of a surgical procedure that, although more profitable for them, is no more effective than cheaper alternatives. Walley et al (2000) found that financial incentives associated with prescribing can encourage changes in GP behaviours, while the use of 'fee-for-service' has the potential to induce demand through incentivising repeat visits and over-provision of care (Brick et al, 2012;Godager and Wiesen, 2011;Gosden et al, 2001;Green, 2014).…”

Section: Doctor Self-interest: Income-seeking Behaviourmentioning

confidence: 99%

Balancing altruism and self-interest: GP and patient implications

O’Riordan

2018

The Irish Journal of Management

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This paper explores how general practitioners (GPs) address potentially opposing motivations stemming from being altruistic and self-interested, and the implications for patients and GPs. The author finds that GPs address dual goals of patient care and profit generation. This can be challenging, while professional values (altruism) encourage a patient focus, business realities (self-interest) mandate other priorities. Viewing clinicians as altruistic in isolation of business needs is unrealistic, as is the notion that profit is the dominant motivation. A blending of interests occurs, pursuing reasonable self-interest, patients’ best interests are ultimately met. GPs need a profit focus to sustain/improve the practice, benefitting patients through continued availability and capacity for enhancement. Therefore, it is argued that GPs behave in a manner that is ‘part altruistic, part self-interested’ and mutually beneficial. These insights should be considered in designing incentive systems for GPs, raising compelling questions about contemporary understanding of the nature of professionals.

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“…4,6 It has proved satisfactory for the patient as well as enriching, complementing and granting prestige to the activity carried out by the primary care doctor.…”

Section: Introductionmentioning

confidence: 99%

“…The main difference is that in Spain its practice does not imply an economic incentive. 4,8 The need of an initial investment in equipment and its maintenance is an essential requirement when starting a programme in minor surgery. In some cases this may be a disadvantage 7 even though expenses in surgical material in primary care result in being more cost-effective.…”

Section: Introductionmentioning

confidence: 99%

Minor surgery activity in primary care

et al. 2010

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ObjectiveThe aim of this study was to describe the activity in our Outpatient Minor Surgery unit during its first five-year period.DesignRetrospective descriptive study.MethodsIt was carried out in two centres of a Basic Health Area with a catchment area of 73,000 inhabitants.ParticipantsPatients who underwent surgery from January 2002 to December 2007 were included in the research.Main outcome measuresInformation on the sociodemographic data of the patients, characteristics of the lesions, risk factors, treatment and its complications was gathered.ResultsA total of 2317 surgical procedures was performed on 1520 patients. The mean was 46 years old and 52% were men. The concordance between clinical and anatomopathological diagnosis was 81%. There were complications in 5% of them. The main pathologies were: epidermoid cysts (22%), nevus (20%) and fibromas (18%). They were mainly located in the back (24%), superior extremities (14%) and head (11%). In 73% mepivicaine was used as anaesthetic. The most current techniques used were: incision (36%), curettage (33%) and fusiform excision (28%). Less than 1% had malignant lesions, 50% of which were not diagnosed clinically. The mean waiting time was 30 days. Ninety-two percent had the informed consent.ConclusionsMinor surgery in primary care is feasible and has a good clinicopathological concordance and minimum complications, but some malignant lesions are overlooked in the diagnosis based exclusively on clinical criteria.

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Impact of the introduction of fee for service payments on types of minor surgical procedures undertaken by general practitioners: observational study

Cited by 7 publications

References 2 publications

Outpatient services and primary care: scoping review, substudies and international comparisons

Outpatient services and primary care: scoping review, substudies and international comparisons

Balancing altruism and self-interest: GP and patient implications

Minor surgery activity in primary care

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