Use of Clinical Quality Indicators
The use of clinical quality indicators to maximise the effectiveness of general practice and improve health outcomes can be very effective. Critical to their effectiveness however is the accuracy of the data used.
Where a third party chooses to use clinical quality indicators as a means to influencing the actions of general practice, then in addition to the need for accuracy of data, they will need some form of incentive linked to the achievement of particular targets. Such incentives will only be effective if they flow through to general practice and are of sufficient value as to make general practice want to achieve those targets. Care also needs to be taken that the system created or targets used do not create perverse incentives.
Performance Management Programme
In recent years the Government has set up a Performance Management Programme (PMP)
with the aim of improving the health of enrolled populations and reduce
inequalities in health outcomes. The tool used to do this is to provide PHOs
with incentive payments for improvements in performance against a range of
specified nationally consistent indicators. PHOs in turn must rely on general
practice to meet these targets.
While we endorse the aims of PMP at present there are a number of problems with it that are of concern to general practice. These are:
- It is essential that general practice plays a major role in the governance of the programme, particularly given that the system relies heavily on general practice undertaking the work. This is not currently the case.
- Clinical governance of PMP project groups is variable in quality. In particular clinical governance groups need to better manage the weightings given to performance indicators as at present the system can require large amounts of a nurse's time reading through CVD data for inadequate remuneration.
- As noted above, many of the requirements are placed directly on GP practice but the incentive payments are made to PHOs. Whether a GP practice receives some or all of the incentive payment depends on the PHO's discretion as to how it uses those payments, and the performance of other GP practices covered by the PHO. In our view there needs to be specific provision made for payment to practices in the contracts between PHOs and practices.
- The system requires general practice to undertake a significant amount of administration however the compensation or recognition of this is highly variable;
- The system requires general practice to have a significant level of IT support, however there is no assistance in acquiring and/or maintaining this;
- Target setting for indicators generally occurs after the time period it covers. For example, the target setting for all indicators for the period 1 January 2007 to 31st March 2007 was set in July 2007. Targets for the period 1 April 2007 to 30th June 2007 as at the end September 2007 have still not been set.
- There are significant problems with the data essential to the achievement of the indicators, including lack of completeness, dated information and inaccuracies. This is seen most clearly in influenza and immunisation data. As a result many practices lose confidence in the data collected.
- Incentive payments are based on the greatest increase in performance against key measurables. The result is that those performing well prior to entering the programme are disadvantaged as opposed to those previously performing poorly.
In summary, the NZMA
- Endorses the use of appropriate clinical quality indicators as a mechanism for improving health outcomes.
- Supports the current PMP in principle however, the problems noted above need to be urgently addressed.
- Calls on the Government and PHOs to rectify the anomalies in the PMP system
noted above and evaluate the effectiveness of this programme.