Editor’s blog 7th August 2008: P4 / 2P = pay to play?

The curse of the TLA (three-letter acronym) is a heavy shadow hanging over the wonderful world of the NHS. In particular, dual definitions can be fun.

In the distant past, when I used to participate in silence-defacing live music activities (those dear, dead days beyond recall), one of the listing acronyms used to shortcut the small ads charges was ‘P2P’  for ‘pay to play’, a sure sign the a music venue was unconfident of its ability to attract people and so that performers wanting the experience of paying there would contract to fork out if they fell below a certain number of paying punters to see them. It was quite like take-or-pay ISTC contracts, really.

So imagine my confusion (OK, you have ample evidence of it already) when in the late 1990s, P2P became the file-sharers’ acronym for ‘peer-to-peer’ networks such as Napster, Kazaa and LimeWire – allowing even more outrageous acts of music piracy.

And I was entertained by Tom Smith sending me a recent report in the BMJ of a paper published in top US journal Heath Affairs (Health Affairs 2008;27:1167-76) that its near-neighbour P4P is now used for ‘pay for performance’ for clinicians. The report appears under the title ‘Performance related pay doesn't improve quality of primary care, US study finds’.

Readers, it does what it says on the tin. A large study in Massachusetts has apparently found that performance-related pay for doctors in primary care does not result in better quality of care for patients.

Overturning preconceptions, or too little cash?
This would appear to overturn much of what we preconceive about how to motivate GPs in the NHS. So why is this the finding of a study of almost 5,000 ‘primary care physicians’ and four million patients?

The researchers propose that the reward schemes on offer by these US commercial health plans may be too low to make a difference to their performance.  The study, which involved about 5000 primary care doctors and nearly four million patients, found that the performance of most doctors improved on all measures of clinical quality regardless of incentives.

The BMJ report notes that P4P has been widely introduced in the USA “as a way to improve patients' care”. Yet the Health Affairs authors suggest that few studies have evaluated its effectiveness. They note that Medicare (the federal health insurance programme for elderly people) has implemented performance-related pay in hospitals, and may introduce payments to individual doctors.

The UK is not the USA, very obviously. Their primary care physicians earn even more than ours. Furthermore, we have had incentivised pay for GPs since the introduction of the new GP contract in 2004. We don’t. of course, have a meaningful control group who did not alter their practice.

Yet at a time when the 2008-9 Operating Framework has introduced patient-reported outcome measures to affect payment and the Darzi review has specified incentives for quality, this news is interesting.

The quality and outcomes framework (QOF, which in truth has little in it causally related to outcomes, though this will surely change) can largely be defined as what GPs should really have been doing anyway.

In the other Mr Blair’s classic novel 1984, the hero Winston Smith wirtes that “freedom is the freedom to say that 2 + 2 =4. From that, all else follows.”  If P4P (pay for performance) is less about P2P as in peer to peer and more about P2P as in pay to play, we are all going to be in deep trouble.