Do Personal Medical Services contracts improve quality of care? A multi-method evaluation

Abstract

To assess whether the new contractual arrangements of first-wave Personal Medical Services (PMS) practices in England improved their quality of care, compared with changes in care provided in a control sample of General Medical Services (GMS) practices. Controlled 'before' (at or near 1 April 1998) and 'after' (at or near 31 March 2001) quantitative observational study in a sample of 23 PMS and 23 GMS practices. Quantitative data focused on access, chronic disease management, mental health care, primary care of older people, costs and patient evaluation using the General Practice Assessment Survey. Case studies were also undertaken in all PMS pilots, involving interviews with general practitioners, nurses, practice managers and Health Authority and Primary Care Group/Trust managers, documentation review, and analysis of site-specific data. There were improvements in quality of care in PMS sites in all areas of care evaluated, but improvements in care over and above those found in GMS sites (the 'PMS effect') were only statistically significant for angina care (P = 0.05) and elderly care (P = 0.04). Teamwork, shared culture, clear objectives and leadership were important catalysts for quality improvement in PMS sites. Improvements in PMS practices came at additional financial cost. There were concurrent improvements in GMS practices. No PMS site succeeded in meeting its aims without successfully introducing effective leadership and management, and changing relationships within the practice (e.g. equalising power between nurses and doctors). Small but steady improvements were observed in English primary care. PMS contracts facilitated quality improvements in specific areas over and above these broad improvements (the 'PMS effect') during the study period. New contractual arrangements for health care can be used to improve quality of care. However, the mechanisms that resulted in quality gains, while facilitated by the new contractual arrangements, were not specific or unique to the PMS experiment. Factors such as effective management, clear objectives and flexible professional relationships within practices are likely to be important in determining whether new contractual arrangements result in improved outcomes. The context within which care and services are provided is as important for quality innovations as specific contractual arrangements.