The effects of structure, process and outcome incentives on primary care referrals to a national prevention programme

Abstract

Despite widespread use, evidence is sparse on whether financial incentives in healthcare should be linked to structure, process or outcome. We examine the impact of different incentive types on the quantity and effectiveness of referrals made by general practices to a new national prevention programme in England. We measured effectiveness by the number of referrals resulting in programme attendance. We surveyed local commissioners about their use of financial incentives and linked this information to numbers of programme referrals and attendances from 5170 general practices between April 2016 and March 2018. We used multivariate probit regressions to identify commissioner characteristics associated with the use of different incentive types and negative binomial regressions to estimate their effect on practice rates of referral and attendance. Financial incentives were offered by commissioners in the majority of areas (89%), with 38% using structure incentives, 69% using process incentives and 22% using outcome incentives. Compared to practices without financial incentives, neither structure nor process incentives were associated with statistically significant increases in referrals or attendances, but outcome incentives were associated with 84% more referrals and 93% more attendances. Outcome incentives were the only form of pay-for-performance to stimulate more participation in this national disease prevention programme.

Population level impact of the NHS Diabetes Prevention Programme on incidence of type 2 diabetes in England: An observational study

“…We collated data on practice characteristics based on our previous analysis of practice referral activity. 24 Characteristics included: the practice's contract type; whether the practice could dispense as well as prescribe; whether the practice was located in an urban or rural area; total payments received per registered patient weighted for need by the Carr-Hill capitation formula; 25 whether the practice received additional income than was recommended by the capitation formula through the Minimum Practice Income Guarantee (MPIG); and the first quality rating that the practice received from the national regulator, the Care Quality Commission.…”

Implications for future policy implementation: a qualitative evaluation of the national rollout of a diabetes prevention programme in England.

“…In our previous papers (18) (22) we reported how implementation monies were used to provide nancial incentives to general practice to increase the number of referrals onto the programme. At the second time point, some case sites were still using a variety of nancial incentives; however, variation within local sites was reported, with some CCGs offering nancial incentives, while others in the same local sites did not.…”

Breaking the quality-equity cycle when implementing prevention programmes

“…A recent study, also based on the NHS DPP, found that outcome incentives (ie, payments linked to the number of patients referred) were associated with statistically significant increases in referrals and attendances. 16 Structural incentives (ie, lump sum payments to support necessary infrastructure) and process incentives (ie, payments linked to actions taken in the process of generating referrals) did not appear to stimulate participation in the DPP.…”