What effect has the devolution of nations had in terms of quality and outcomes?
It has been more than fourteen years since Scotland and Wales gained devolved government with Northern Ireland only a couple of years behind them. From the start healthcare was a devolved matter, meaning that the devolved governments were responsible for the NHS in their area, as well as public health and more general health matters.
What effect has the devolution of nations had in terms of quality and outcomes?
It has been more than fourteen years since Scotland and Wales gained devolved government with Northern Ireland only a couple of years behind them. From the start healthcare was a devolved matter, meaning that the devolved governments were responsible for the NHS in their area, as well as public health and more general health matters.
The definition of a national service in this context might be a little strained, but for the most part services continued as before. Basic eligibility for public health services remained the same. Treatment of patients by GPs and in hospital continued in much the same way. Indeed in border areas patients could be treated in what were technically separate systems and not really notice the difference. The freedoms afforded by devolution were used in a variety of ways but with common themes. Inevitably there have been changes in the management structures in these countries. In many ways it is England that has moved away from the devolved countries. In the various reorganisations there has been a general emphasis on co-ordination and whole system planning rather than the market of commissioners and providers, which has been the dominant model in England over the last decade.
Charges for health services have been a priority for devolved governments. There is now no charge for NHS prescriptions in any part of the UK outside England. Personal care is also without charge in Scotland, ending much of the conflict that patients can see between the health and social care systems.
There are also differences in outcomes between the systems. A recently analysis in the BMJ looked at outcomes and productivity in the four countries. In general the NHS in England was felt to be the most productive although there were considerable differences between the statistics gathered in each country, making comparison difficult. Many things remained the same in each country. Available treatments did not vary much across the UK. Career structures and professional regulation remained unified. Contracts for medical staff and GPs were negotiated at a UK level. There would be some differences in enhanced services but they were generally no more different than between different primary care trusts (PCTs) in England.
Up until this year there was no difference in the general medical services (GMS) contract across the UK. Despite the introduction of the quality and productivity (QP) indicators two years ago, which were based much more on the English model of healthcare, the contract remained united. However this relationship was pushed to breaking point when Westminster announced a plan to impose contract changes to the GMS contract in England.
In the subsequent four months all three devolved administrations negotiated contract changes. There was no imposition outside of England and as a result the changes are generally less severe in the devolved administrations.
The biggest financial consideration for every practice is from the global sum and the associated correction factor – also known as the minimum practice income guarantee (MPIG) – on top. This was introduced with the contract in 2004 as the funding formula produced excessive swings in practice income. In short it was felt not to work properly. The formula has not changed materially over the last nine years.
In England the correction factor is to be withdrawn over the next seven years. Northern Ireland has decided not to remove the factor, and in Wales, which has a high number of small rural practices, there is to be further review before any change is made. There have always been variations in funding between practices in different countries and Celtic practices have not traditionally done very well out of the current formula. In general we can expect global sum to practices in England to fall behind those of Wales and Northern Ireland in the second half of this decade.
Even in Scotland, 77 of the points no longer required in the QOF will be transferred to the Global Sum, based on the average achievement over the past three years. The changes that GPs are most familiar with are in the area of the quality and outcomes framework. In England the whole of the organisational domain was removed and the cash released was used to fund four new Direct Enhanced Services (DESs). (See thecommissioningreview.com for a full article on this topic). One of the arguments for this removal is that many of the standards duplicate care quality commission (CQC) regulations and will be enforced by them – the carrot is to be replaced with a stick.
The CQC only regulates health care in England so this argument is less persuasive in other parts of the UK. As these DESs are exclusive to England, alternative arrangements were required in the rest of the UK. In Northern Ireland, 23 points remain in the medicines management section of the organisational domain. Two indicators, the first for meeting a medicines management adviser from the Regional Board and agreeing three actions and the second for carrying out those actions gain seven points each. There are a further nine points for 80% of patients who are on four or more repeat medications having an annual review. Scotland has kept the same three organisational indicators but their points allocation is a little different with four points for the meeting, nine for carrying out the actions and 10 for medicines reviews. In Wales the organisational domain is rather larger than in either of these two countries; 59 points will remain.
As well as the medicines management indicators which the other two countries have retained there are indicators remaining for medication reviews on all patients on any number of repeats as well as the timeliness of repeat prescriptions and the maintenance of emergency drugs within the practice. Seven points remain in the practice management area with three indicators for child protection, appointment times and identification of carers.
In the education area in Wales there are three points for an annual review of complaints and a total of 10 points across two indicators for significant event review. A further three points have been retained for the passing of information to and from out of hours services.
The QP domain has previously had the most “English” view of the health service. The is one of the few cases where there have been active changes to the QOF rather than purely retention of previous indicators.
Northern Ireland has chosen to keep these indicators broadly the same as England with three indicators each for out patient referrals, emergency admissions and accident and emergency attendances. These areas carry 21, 48 and 31 points respectively.
In Scotland the QP indicators about out patient referrals remain broadly the same. The remaining six indicators, with 79 points between them, are based around identifying patients most at risk of emergency admission and delivering an anticipatory care plan for a selection of these patients. In this year this will be a total of 0.75% of the practice list and will rise to 1.5% next year. In England risk profiling sits in a separate DES and is rather less funded, although there is probably more work in the Scottish QP indicators.
Wales plots a middle course with the indicators for out patient referral and emergency admissions being similar to England and 47.5 points available for active management planning for half a percent of the practice list. The meetings required, the payment and the number of patients involved are similar to the English DES.
There is rather less variation in the clinical indicators. The National Institute for Health and Care Excellence (NICE) committee, which puts forward indicators for development, currently represents all four countries.
Although initially planned for inclusion, the indicator requiring all patients newly diagnosed with heart failure to have a referral to an exercise-based rehabilitation programme was not implemented in England, Scotland and Northern Ireland. This has remained in Wales with five points for getting 90% of patients referred.
Wales has also included the need to annually refer patients with chronic obstructive pulmonary disease (COPD) and a dyspnoea score of three or above to a pulmonary rehabilitation programme. Again this was proposed in the rest of the UK but not implemented as it was felt to be unworkable. In England the target blood pressure for patients on the hypertension register fell from 150/90 to 140/90 for patients under 80 years of age in 2013-14. In Wales the target is the same as England. For Scotland and Northern Ireland the target remains the same as previously – 150/90 for patients of all ages.
In addition none of the countries outside England have implemented the indicators requiring exercise assessment (GPPAQ) and advice for patients on the hypertension register. Those indicators are fairly poorly rewarded in England and are not thought to be feasible in other countries.
Apart from the indicators themselves, the major variations between the countries are about how these are implemented. The two major changes in England have been the reduction in the time to attain most of the indicators from fifteen to twelve, and the raising of thresholds in twenty indicators, with the rest to follow next year. The upper thresholds are to be moved the to the 75th centile. This is based on the most recent data available, two years behind the current year. This means the threshold will be set at the level of the top quarter of practices. Wales has a similar system, but the threshold is set at the fiftieth centile. Although this sounds quite different the actual thresholds are fairly similar due to practice achievement being quite bunched together. Scotland has only increased ten indicators, and these increases are smaller with a maximum upper threshold of ninety percent. In England the majority of the increased thresholds are over 90%, and two are set at 100%.
Thirteen indicators have had their upper thresholds increased by 5% in Northern Ireland but in these cases several of the lower thresholds – where practices start earning points – have been increased to 60%.
The contracts in Scotland, Wales and Northern Ireland are more similar to each other than to the English contract. However the main bulk of all the contracts remain the same. There are hundreds of pages of the GMS contract that are identical in all four countries.
The QOF and enhanced services are the parts of the contract that feature most strongly in the day-to-day life of GPs and have a large influence on practice finances. England got, from the GPs’ point of view, the worst of the deals. It is probably a bit early to say but there could even be an influence on recruitment. These negotiations were conducted in something of a hurry. It seemed to be a surprise to everyone when the English imposition was announced in November. With more time there may have been bigger differences.
Finally, we should not underestimate the psychological effect of splitting the contract across the UK. If disaster does not unfold (and there seems no reason that it would) it is likely that the devolved administrations will be encouraged to pursue their own policies further. There is no reason that they should not co-operate in some areas to produce completely novel indicators.
