In his recent paper, Professor Robert West highlights the potential benefits and risks of adopting a ‘payment by results’ approach for smoking cessation services .
Eight Primary Care Trusts (PCTs) in the West Midlands have been developing such an approach and introduced payment-by-results (PbR) contracts in April 2010. It is one of a number of PbR development projects sponsored by the Department of Health .
The objective of the project is to increase the supply and uptake of high-quality stop smoking services. We planned to achieve this by creating a system in which existing providers of smoking cessation services are supported to increase their supply; new, suitably qualified suppliers are able to enter the market and both new and existing suppliers are reimbursed appropriately for the outcomes they achieve. All suppliers must deliver services in line with a detailed service specification which is based on national guidance . Providers receive payments for both 4- and 12-week quitters.
West identifies a number of potential risks associated with a PbR approach. These risks were identified at the outset of the project, and specific actions were taken to mitigate these risks.
West warns that providers may ‘cherry-pick easy cases’ to maximize income. In the West Midlands project, higher tariffs are paid to suppliers that deliver quitters from certain, pre-defined population subgroups to tackle health inequalities.
West suggests that providers should be paid only for successes that are above a threshold which might be expected if no intervention were delivered. While we share West's concerns, such an arrangement would be difficult to administer, driving up transaction costs which could otherwise be spent on service delivery. Instead, the commissioners have adopted a simpler, pragmatic approach to address this concern. Fees are paid to providers for all patients who quit, but the contract specifies a minimum threshold for both quit rates and the quantity of behavioural support provided. Performance clauses in the contract may be applied where providers fail to meet these standards.
West recommends that providers should first be accredited before delivering services. In the West Midlands project, providers must pass a rigorous accreditation process which makes an assessment of their approach to behavioural support, provision of pharmacotherapy, methods of assessing nicotine dependence and smoking status, adviser training, etc. These assessments are made by experienced smoking cessation commissioners.
Providers are required to submit a detailed data set for each patient setting a quit date. These data sets are used for payment, contract monitoring and audit purposes.
There are now more than 70 National Health Service (NHS), voluntary and private providers delivering smoking cessation services in the participating PCTs, many with substantial networks of subcontractors.
In 2010/11, the number of 4-week quitters delivered in the eight participating PCTs rose by 9% over the previous 12-month period. Carbon monoxide validation rates increased and equity of access has improved. Figures for the first quarter of this year suggest that activity will rise further in 2011/12.
The results of an independent evaluation of the project will be published at the end of 2011.