GPs 'Reduced Alcohol Advice' When Financial Incentives Stopped

Nicky Broyd

October 10, 2019

Financial incentives for GPs in England to talk with new patients about high alcohol consumption were introduced in April 2008 and resulted in a small increase in both screening and the provision of advice given to heavy drinkers.

A new large-scale study looking into the impact of the scheme has found that when the incentive was withdrawn in April 2015 screening rates and advice decreased immediately. They have been low ever since.

Lead author of the study, Amy O'Donnell, PhD, Institute of Health and Society, Newcastle University, told Medscape News UK that "the sharpness of the decline was a surprise" which led her to cross check the data. "We found some publicly available NHS digital data, and that actually corroborated our findings. But the significant decline, post incentives did come as more of a surprise."

The study findings were the result of analysing an electronic dataset of more than 4 million newly registered patients and have been published in the scientific journal Addiction .

The Royal College of GPs (RCGP) said alcohol addiction is taken very seriously and  GPs will still be discussing alcohol consumption with their patients. 

Advice Increase

Before the introduction of the financial incentive scheme (1st January 2006 – 31st March 2008) out of every 1000 eligible patients per month, 92 were screened for higher risk drinking, and fewer than 15 in every 1000 screen-positive patients received brief advice.

After the incentive scheme was introduced, (1st April 2008 – 31st March 2015) participating GP practices were paid £2.38 for each newly registered adult patient they screened for higher-risk drinking.

The study found this had little impact on screening rates but led to an immediate increase in the provision of advice, with just over 20 more higher-risk drinkers receiving support per month for every 1000 patients that screened positive.

Once the financial incentive was discontinued, (1st April 2015 – 31st December 2016) the rate of screening fell by almost three patients per month and out of every 1000 screen positive patients, 31 fewer were receiving brief advice about their higher risk drinking habits.

Dr O'Donnell said: "Scaling-up our findings to the English population, we estimate that by the end of 2016 alone, 27,000 fewer patients received brief advice as a result of terminating the alcohol incentive scheme. This is despite the fact that GPs are still legally obliged to identify and support higher-risk drinkers."

Imperfect Incentive

Dr O'Donnell believes a number of factors contributed to the decline.

"In terms of the limited impact and then the tailing-off since that point, we know that the scheme itself wasn't perfectly designed by any means. And the incentive itself was pretty low, particularly if you compare the enhanced service scheme to areas that are covered by the Quality and Outcomes Framework (QOF), for example. There was limited incentive for GPs from the get-go.

"We also know the incentive only paid GPs to screen their patients. So in terms of it being a lever to thoroughly embed that sort of alcohol prevention approach, again, it was imperfect.

"If you're going to have an incentive scheme it needs to encourage clinicians to deliver the whole pathway, so not just identifying whether you've got heavy drinkers in your patient population, but actually delivering some support to those patients themselves once you know that."

Tick Box Exercises

In a statement, RCGP chair Professor Helen Stokes-Lampard, said: "What this research shows is that when incentives exist for GPs to perform certain tasks, they are more likely to record it in a certain way - and that in a stretched NHS, additional resources do help us to do this. However, GPs will still be discussing alcohol consumption with their patients where appropriate, and providing advice to those who have a problem, but not recording it in the standardised way in which they were previously required to receive payment, particularly if this was not the main focus of the consultation.

"Ultimately, it is important that GPs are able to use our expert skills to target health advice to patients when we consider it of genuine benefit to them, instead of doing so as a tick box exercise. Any scheme to ensure good quality outcomes in patient care is based in evidence - and this indicator around alcohol consumption will have been removed for a reason."      

Improving Future Incentives

In future, Dr O'Donnell says: "If we're going to introduce incentives again for alcohol prevention work, I think the only meaningful way to do it would be to add it to the Quality and Outcomes Framework. I don't think that smaller standalone incentives are going to work."

She says she would also like to see more clinically relevant targeting of patients so any new incentive included more middle-aged patients, and more people with conditions already associated with alcohol like long-term depression and high blood pressure.

She would also like better feedback around the work GPs already do: "Even though they don't have the incentive, we know that GPs still have it in their contract that they should be screening newly registered patients for heavy drinking. I'd like to see some level of effective audit and feedback around that."

The study highlights the problems associated with using short-term financial incentives to boost alcohol prevention in primary healthcare in England but Dr O'Donnell believes there is an opportunity to learn from the direction NHS Scotland is taking: "They've already had a substantial alcohol 'brief advice' programme that I know that they're currently doing work to reinvigorate, improving the training and promotion of that programme of work. It would be great if the rest of the UK could follow that example."

This research was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR) and further supported by a research innovation grant from Alcohol Change UK (R2016/01).

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time–series analysis. Addiction. 9th October 2019 doi/10.1111/add.14778

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