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(1) Pay for performance has improved blood pressure monitoring and reduced health inequalities
(2) Credit crisis could mean bleak future for the NHS, warns expert

(1) Pay for performance has improved blood pressure monitoring and reduced health inequalities
(Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework)
http://www.bmj.com/cgi/content/abstract/337/oct28_2/a2030
(Editorial: The UK quality and outcomes framework)
http://www.bmj.com/cgi/content/extract/337/oct28_2/a2095

Pay for performance has substantially improved blood pressure monitoring and control in England, and the difference in monitoring levels between the most and least deprived areas has all but disappeared..

This study adds to the evidence that the Quality of Outcomes Framework (QOF) is a "truly equitable public health intervention", says the author of an accompanying editorial.

High blood pressure is the single most important risk factor for developing heart disease and adds significantly to the gap in life expectancy between deprived and affluent areas. Studies have shown that successful blood pressure control could prevent 43 000 strokes and 83 000 cases of heart disease in the UK each year, but this is less likely to be achieved in socially deprived areas.

The QOF was introduced in 2004 to improve standards of primary care by linking financial incentives to 135 performance indicators for all general practitioners in the UK. It includes the target of blood pressure monitoring of all primary care patients older than 45 years annually, and meeting blood pressure control targets in patients with chronic diseases such as hypertension and diabetes.

In the first year of its implementation (2004-5) practices in socially deprived areas reported lower achievement scores (6.1% of the total QOF score) and therefore less financial reward than the more affluent areas, but by year 2 the gap had reduced to 2.9%.

Dr Mark Ashworth and colleagues from Kings College London, report on the data from the first three years (2004-7) of the QOF's implementation, including more than 8515 (97%) of practices in England involving 53 million people. They examined the effect of social deprivation on the achievement of blood pressure targets between general practices in deprived and less deprived communities in England.

The authors found that blood pressure recording increased from 82.3% (52.8 m) of adults in 2005 to 88.3% (53.2m) in 2007, and that the gap between median blood pressure recording levels narrowed from 1.7% to 0.2% between practices in the most deprived and least deprived areas.

Over the past decade, data has shown steady improvements in population blood pressure control, but the findings of this study show a rapid improvement in the last three years.

In addition, the achievement of blood pressure targets for the five chronic diseases improved substantially, particularly in diabetics in the most deprived practices, which improved by over 10%, with over 79% achieving target blood pressure levels by 2007.

The study shows that performance indicators linked to financial incentives result in improved achievement of targets, which at the same time narrows health inequalities, conclude the authors.

"Perhaps the greatest contribution that the QOF has made to changing practice will therefore be the largely unintended consequence of generating more equitable healthcare", says Professor Helen Lester from the National Primary Care Research and Development Centre in an accompanying editorial.

This study and other evidence suggests that pay per performance schemes should be designed with health inequalities in mind, she concludes.

Contacts:
Dr Mark Ashworth, Department of General Practice, Kings College London, London, UK
Email: Mark.Ashworth@gp-G85053.nhs.uk
Editorial: Professor Helen Lester, National Primary Care Research and Development Centre, Manchester, UK
Email: Helen.lester@manchester.ac.uk

(2) Credit crisis could mean bleak future for the NHS, warns expert
http://www.bmj.com/cgi/content/full/337/oct28_2/a2259
(Feature: The credit crisis and health care)

At best the NHS might expect no real growth in funding from 2011, warns John Appleby, Chief Economist at The King's Fund, on bmj.com today.

Lower or capped NHS spending together with the health impacts of unemployment and deprivation caused by the credit crisis and looming recession could rock the health service in the future, he explains.

Currently, inflation is high and will reduce the spending power of the NHS—every 1% increase will cost the health service around £380 million.

Higher prices also means more pressure on NHS staff's disposable income. This could mean higher wage claims and calls for contract renegotiation. However, inflation is predicted to reduce sharply next year, and with a three-year pay deal in place for most NHS staff, such calls will be strongly resisted by the government.

Although the prime minister pledged not to cut spending on health, with foundation trusts reporting cash balances of £2.5 billion and the rest of the NHS planning a surplus of £1.7 billion, the government may look to claw back end of year NHS surplus funds - taking back unspent money may not be viewed as a cut, he writes.

Short term, the credit crisis has already had an impact on private sector health providers and foundation trusts, claims Appleby. Virgin Healthcare has already pulled back from plans to enter the health market and it is likely that future private finance initiative schemes will slow down. And some foundation trusts are currently negotiating the security of deposits in failed Icelandic banks.

It is the long term effects of the credit crisis which particularly concern Appleby: "NHS spending is guaranteed up to April 2011, what happens after then looks decidedly less rosy. The health service will almost certainly have to plan for lower growth in funding from 2011 onwards."

With reducing tax revenue and increased government spending to support borrowing, the best the NHS might expect, he says, is no real growth in funding in the next spending round from 2011 to 2014, combined with a real pressure to cut costs. The NHS will have to move quickly to prioritise value with much more emphasis on improving productivity, he says.

Added to this, rising unemployment (increasing the government's spending on benefits), increasing ill health and the associated increase in demand for healthcare services, makes the longer term forecast bleak. However, Appleby states that the NHS is now better equipped to deal with the economic downturn than in previous years, with almost two thirds of trusts now showing solid financial management.

Appleby points out that the UK government's financial system bailout using £387 billion of taxpayers' and borrowed money will push national debt to over half the UK's gross domestic product and this, he says, will inevitably affect public services.

It will at some point and to some degree have to be born by the NHS and so it is essential that preparations are made for the inevitable difficult financial and health future, he concludes.

Contact:
Press Office, King's Fund, London, UK
Email: mediaoffice@kingsfund.org.uk

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