The National Health Service wants to launch a program in the UK that would provide cash payments to citizens to incentivize them to see their primary care doctors to deal with health problems such as diabetes, heart disease and obesity.

National Health Service managers are looking to get higher-risk patients into the system sooner for prevention. As in the US, the UK suffers from health disparities between urban and rural populations, and between people from different socioeconomic classes.
The idea is being promoted by the North-East Essex primary care trust. This area covers about 315,000 citizens of Colchester and Tendring. See Colchester on this map of the Essex region.

Some background: the NHS organizes primary care at the local community level. These groups are called Primary Care Trusts (PCTs), and they control about 80% of the total NHS budget. They fund general practitioners and prescription drugs, as well as commission hospitals for inpatient services. There are 300 primary care trusts in the UK.

An integral part of what the trusts do is to determine the public health needs of their local citizens. Thus, the North-East Essex primary care trust seeks to tackle the issue of getting people into preventive health habits.

The plan is to offer cash payments — which some opponents call “bribes” — as incentives to go and see their GP for advice.

The plan is controversial for a couple of reasons. The preeminent concern is one I wrote about in February 2008 in Health Populi, “What’s so nice about NICE?” which discussed the UK’s approach to evaluating new medical technologies, including prescription drugs. Cancer patients in the UK have found themselves diagnosed with the disease but denied access to drugs they and their physicians believe would be useful treatments.

Thus, the idea of providing payments to patients with chronic conditions can be seen as diverting funds that might be more usefully spent on drugs for more ‘serious,’ life-threatening diseases such as cancer.

The Trust sees the payments could take the phone of mobile phone cards or other in-kind modes. The chief of the Trust is also looking at other ways to remedy peoples’ chronic health issues, such as paying for heating bills to prevent chronic chest infections. Note that the Trusts are also responsible for whole health, including social services.

For more on this story, see the BBC coverage of it here from October 3, 2008.
Health Populi’s Hot Points: As Goethe wrote, “there are no new ideas.” The NHS incentive-payment program reminds me of the Asheville Project, which began in the City of Asheville, a self-insured employer, in 1996. Among many moving-parts to this project was a tactic to reduce or even eliminate the co-payment for prescription drugs addressing chronic conditions such as asthma, diabetes, high cholesterol, and hypertension. As a result, citizens’ health outcomes improved because their health behaviors improved — specifically, their adherence to therapeutic drug regimens.

The tactic of payment for changing health behavior (whether cash, free co-pay, or object-in-kind) would also fall into the strategy of “nudging” for good outcomes. See more on the Nudge approach in Health Populi, “Nudging out way to healthy behavior,” in April, 2008.

The cash-for-primary-care approach falls under the large umbrella of value-based medicine — funding what works, not paying for what doesn’t, and measuring patient outcomes along the way. But in a budget-based environment such as that of the Primary Care Trusts in England, the fiscal tradeoffs between prevention and cure (a la cancer drugs) is more transparent.

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