Abstract
This paper focuses on financial incentives rewarding successful implementation of guidelines in the UK National Health Service (NHS). In particular, it assesses the implementation of National Institute for Health and Clinical Excellence (NICE) venous thrombo-embolism (VTE) guidance in 2010 on the risk assessment and secondary prevention of VTE in hospital in-patients and the financial incentives driving successful implementation introduced by the Commissioning for Quality and Innovation for Payment Framework (CQUIN) for 2010-2011. We systematically compared the implementation of evidence-based national guidance on VTE prevention across two specialities (general medicine and orthopaedics) in four hospital sites in the greater South West of England by auditing and evaluating VTE prevention activity for 2009 (i.e. before the 2010 NICE guideline) and late 2010 (almost a year after the guideline was published). Analysis of VTE prevention activity reported in 816 randomly selected orthopaedic and general medical in-patient medical records was complemented by a qualitative study into the practical responses to revised national guidance. This paper’s contribution to knowledge is to suggest that by financially rewarding the implementation of national guidance on VTE prevention, paradoxes and contradictions have become apparent between the ‘payment by volume system’ of Healthcare Resource Groups and the ‘payment by results’ system of CQUIN.
Highlights
Background to incentive payments in theNational Health Service (NHS) Diagnostic Related Groups (DRGs) offered health organisations the ability to understand provider activity in terms of how many patients they cared for and their case-mix
This paper suggests that in instances where there were unachievable clauses for achieving CQUIN rewards for venous thrombo-embolism (VTE), there was less evidence of an improvement in VTE risk assessment and appropriate prescribing of venous thromboembolism prophylaxis
It indicates the percentage of CQUIN monies allocated to further improving VTE risk assessment by paying for a Lead VTE Nurse or improving staff education in VTE
Summary
NHS Diagnostic Related Groups (DRGs) offered health organisations the ability to understand provider activity in terms of how many patients they cared for and their case-mix. They allowed activity comparison within and between different organisations as well as providing a means of making longitudinal analyses of trends in treatment and service provision. Local adaptations or variants of diagnosis related groups (DRGs) have been adopted as the unit of payments to hospitals in many health systems[1]. This is a system that classifies hospital cases into identifiable groups in order to identify ‘products’ that a hospital provides. This model of classification has spread to other countries including Australia, Denmark, France, Germany, Austria, the Netherlands and Russia; followed by a less rapid spread from acute care into long-term care and psychiatry[2]
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