Qualitative study of pilot payment aimed at increasing general practitioners' antismoking advice to smokers

EDITOR--
Incentive payments for primary care are focused on either outcome or
process and the intervention on smoking studied by Coleman et al is an
example of an outcome incentive (1). However, outcome incentives only
change behaviour if the primary care team believes they can have a
significant effect on that outcome. Interventions on smoking lead to
between 5 and 30% of people to stopping smoking, but this is very
dependant on each patient being at the stage of contemplating change
(2,3). An outcome incentive on smoking will therefore favour efforts to
record who gives up smoking rather than efforts to encourage people to
give up.

Process incentive payments can be more effective than outcome incentives
when the outcome is largely dependant on factors outside the doctor’s
control. However process incentives will only change clinical behaviour if
the process is close to good clinical practice and is recognised to have
benefit. For example, asking about contraception, which is likely to
prevent pregnancies. In contrast, measuring peak flow on every single
asthmatic patient every year will not alter asthma symptoms for more than
a few brittle asthmatics who would be likely to be doing peak flow
already. Incentives like this appear to have been chosen on the basis that
they can be easily verified rather than their clinical effectiveness.

The design of incentives should fulfil the criteria for acceptance of a
screening test. To produce change incentive payments should also be made
for a specific process that is clearly effective, simple, easy to record
and fits with good clinical practice. Sadly most of medicine does not come
neatly packaged like this. As Oman and other have shown on reviews of
interventions there are few “magic bullets” (4,5). In addition, if a
payment is to be a true incentive it should cover the full cost of setting
up the process and provide additional funds that can benefit other aspects
of primary care.

Coleman states “the path of least resistance to claim…(incentives is
often)…simple administrative changes rather than changes in clinical
behaviour” (1). Attempts to change behaviour of doctors in general
practice have led to system of mechanistic hoop jumping, which has
resulted in an increasing administrative workload and a subsequent
reduction in the time for clinical care.

Mark Rickenbach GP and Associate Senior Lecturer

Park Surgery,
Hursley Road,
Chandlers Ford,
SO53 2ZH

rick@chandlers.prestel.co.uk

1) Coleman, T., Wynn, A.T., Stevenson, K. and Cheater, F. (2001)
Qualitative study of pilot payment aimed at increasing general
practitioners' antismoking advice to smokers. BMJ 323, 432-435.

2) Prochaska, J. and DiClemente, C. (1986) Treating addictive
behaviour: processes of change, New York: Plenum.

3) Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G. and
et al (1994) Stages of change and decisional balance for 12 problem
behaviours. Health Psychol 13, 39-46.

4) Oxman, A.D., Thomson, M.A., Davis, D.A. and Haynes, R.B. (1995) No
magic bullets: a systematic review of 102 trials of interventions to help
health care professionals deliver services more effectively and
efficiently. Can Med Assoc J 153, 1423-1431.

5) Wensing, M. and Grol, R. (1994) Single and combined strategies for
implementing change in primary care: a literature review. Int J Qual
Health Care 6, 115-132.