Effect of pay-for-outcomes and encouraging new providers on national health service smoking cessation services in England: a cluster controlled study

Abstract

Background: Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services.

Methods: Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs (representing 2,138,947 adult population) matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level.

Results: The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs (incident rate ratio 1∙108, p<0∙001, 95% CI 1∙059 to 1∙160). Eighty-five providers held 'any qualified provider' contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings.

Conclusions: Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services.

Fig 1. 4-week quits per 1,000 adult population for intervention and control PCTs by cluster: 2009/10 to 2012/13

The figure shows the change in quits over time for the intervention PCTs compared to their comparators in each of the six clusters. The clusters use the Office for National Statistics (ONS) subgroup categories for geographic areas of the UK based on similar local population characteristics. The eight intervention PCTs fall into six ONS subgroups along with 64 other PCTs which form the controls. Intervention PCTs are shown in black and control PCTs are shown in grey. 2009/10 = 0 and 2012/13 = 3.

Fig 2. Enrolled smokers per 1,000 adult population for intervention and control PCTs by cluster: 2009/10 to 2012/13

The figure shows the change in this measure of quits over time for the intervention PCTs compared to their comparators in each of the six clusters. The clusters use the Office for National Statistics (ONS) subgroup categories for geographic areas of the UK based on similar local population characteristics. The eight intervention PCTs fall into six ONS subgroups along with 64 other PCTs which form the controls. Intervention PCTs are shown in black and control PCTs are shown in grey. 2009/10 = 0 and 2012/13 = 3.

Fig 3. CO-validated 4-week quits as a percentage of the enrolled smokers for intervention and control PCTs by cluster: 2009/10 to 2012/13

The figure shows the change in enrolment over time for the intervention PCTs compared to their comparators in each of the six clusters. The clusters use the Office for National Statistics (ONS) subgroup categories for geographic areas of the UK based on similar local population characteristics. The eight intervention PCTs fall into six ONS subgroups along with 64 other PCTs which form the controls. Intervention PCTs are shown in black and control PCTs are shown in grey. 2009/10 = 0 and 2012/13 = 3.