Diabetes Care Improves After UK Reforms Of General Practice, But Ethnic Disparities Remain

Research published in PLoS Medicine examines the impact of the UK government's new contract with general practitioners (family doctors) on the care of people with diabetes. The research, conducted in Wandsworth in London, found that improvements had occurred, but black people of Caribbean origin were not benefiting to the extent of other ethnic groups. This is despite the fact that reducing differences in the quality of health care provided to different patient groups was one of the aims of the reforms. In the UK, as in many countries, people from ethnic minorities are more likely to develop diabetes than the majority population and their condition is typically not so well "managed" - i.e., it becomes more severe more rapidly and there are more complications. Addressing the gap between ethnic groups was one goal in the major health reforms launched by the government, which included the introduction of a "pay-for-performance" contract between the health service and general practitioners (GPs). It was agreed in 2004 that GPs would receive increases to their income that would depend on how well they were judged to be performing. The effectiveness of diabetes care, for which there are defined "treatment targets", is one of the areas in which GPs' performance is assessed. Wandsworth was chosen by the researchers, who are based at Imperial College, London and at the University of Leicester, as it is a very ethnically diverse area of London. The researchers used GPs' electronic records on the 4,200 people with diabetes registered in Wandsworth. Overall, they found that more patients met their treatment targets after the introduction of pay-for-performance management than were doing so before. All ethnic groups seemed to have benefited, but the black Caribbean group did not benefit as much as the other groups; the number of these patients who met the targets did improve, but the gap between them and patients with diabetes from other ethnic groups remained about the same. The UK's use of pay-for-performance in general practice is regarded internationally as a very bold step. As other countries are also considering moving in this direction, the lessons from the study will be relevant in many other parts of the world. In a Perspective article discussing the new study, Katie Coleman and Richard Hamblin (Center for Health Studies, Group Health Cooperative, Seattle, USA) say that the study results show that "pay for performance alone may not be able to drive equitable improvement in health care quality." Citation: Millett C, Gray J, Saxena S, Netuveli G, Khunti K, et al. (2007) Ethnic disparities in diabetes management and pay-forperformance in the UK: The Wandsworth Prospective Diabetes Study. PLoS Med 4(6): e191.

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