Smoking presents a significant burden to the NHS in terms of increased incidence of chronic conditions and early death. Having observed how the United States applies payment incentives to improve care, England is similarly looking to introduce payment by results systems for preventive care, using activity, quality and outcomes-based measures.

Innovation

This cluster controlled study looked at how payment incentives can improve the effectiveness of smoking cessation services in England. The authors compared 8 PCTs with 64 demographically similar primary care trusts.

The unique thing about the 8 PCTs was that they worked with the West Midlands Strategic Health Authority, their host organisation, to develop “a unified approach to piloting new contracts for stop smoking services.” To encourage new providers, this unified approach applied specific criteria, known as “qualification-based provider regulations”. This meant that other organisations, and not just existing NHS community service providers, could apply to deliver smoking cessation services, although they would have to achieve the required clinical outcomes.

The criteria that were set ensured that the quality of health services provided did not diminish, because the new provider would have to meet the same standards that NHS organisations have to deliver. However, by encouraging competition, all the organisations need to be proactive in the way they deliver these preventive services. This may seem unfair to existing services, but learning from other organisations is a good way to refresh current practice, because it helps you to see where the gaps are in service delivery.

Incentives

The payment incentives that were applied within the 9 PCTs differed according to target populations, (e.g. pregnant women, or people working in routine occupations). The payments were made when the number of people giving up smoking increased at both 4 and 12 weeks.

With the introduction of payment incentives and new providers, the 8 PCTS which had adopted the new commissioning policies, found that they were “getting more individuals to set a quit date,” with the largest 10 providers being responsible for 84% of the 4-week quits in 2011/12. These 10 providers were made up of 7 existing NHS community services and 3 new providers, which demonstrates, that adding new providers to the mix does not necessarily have a negative impact on existing NHS services.

Commentary

One could argue that if there are existing NHS community services, why would we encourage new providers? However, this paper demonstrates that by getting service delivery organisations to think of new and better ways of working, and encouraging them with incentives, preventive service provision can be improved.

This is relevant to commissioners as it will have implications for their budgetary decisions. If successful, they will need to pay more in incentives, but then, on the flip-side, if more people give up smoking, there will be less of a burden on the health system. However, payment incentives will have an immediate impact on the budget, while the reduced burden on the health system, will take longer to realise. While this is clearly an effective way to improve services, commissioners will need to ensure that they have sufficient funding available to pay for the incentives, while ensuring that they have enough budget to maintain the same level of service in other areas of health care. Commissioners can use this paper to present a case for using incentives for prevention services.

Considerations for commissioners

• Do you use payment incentives to improve service delivery and effectiveness?
• If not, can you see this working for your area?
• Because of the novelty of innovative solutions, it might be useful to formally share your experiences with other commissioners and encourage them to do the same so that you learn from each other.
• Different payment incentives may be more effective than others, and it is important that this knowledge is shared between commissioners, so that the effectiveness can be cascaded throughout the NHS.

Link

McLeod H, Blissett D, Wyatt S, Mohammed MA. (2015) Effect of pay-for-outcomes and encouraging new providers on National Health Service smoking cessation services in England: a cluster controlled study.  PLoS ONE, 10(4):e0123349 (PDF)