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

Background

Despite substantial evidence for the effectiveness of alcohol screening and brief advice, implementation in primary care systems remains poor worldwide. Financial incentives were introduced in England in 2008 to encourage their delivery. Under the national Directed Enhanced Service scheme, general practitioners (GPs) were paid GBP 2.38 (US$2.2) for each newly registered adult patient they screened to identify problem drinking. However, this incentive was withdrawn in April 2015, replaced by a contractual requirement for GPs to screen all newly registered patients. The impact of these policy changes on alcohol screening and brief advice delivery rates in English primary care has not yet been evaluated.

Materials and Methods

Using a large representative electronic database of primary care patient records (THIN, The Health Improvement Network, n=500 GP practices) we used interrupted time series methods to quantify the impact of the introduction and subsequent withdrawal of financial incentives on rates of newly registered patients aged 16+ (n= 4,278,723): 1) screened for higher risk drinking; 2) screened positive for higher risk drinking; 3) screened positive and received brief alcohol advice. Data related to the period 1st January 2006 to 31st December 2016.

Results

There was no significant change in the monthly rate of newly registered patients screened for higher risk drinking after the introduction of financial incentives in April 2008. However, rates fell significantly (p<0.001) post-withdrawal in March 2015, and by 2.96 (95% CI 2.21-3.70) patients per 1,000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI 3.87-14.23) per 1,000 in the rate of patients screening positive for higher risk drinking, but no significant change in the rate at which this increased over time. Withdrawal of financial incentives was associated with a fall in screen positive rates of 29.96 (95% CI 19.56-40.35) per 1,000 patients, but a rise in the monthly increase in this rate of 2.14 (95% CI 1.51-2.77) per 1,000. The rate of screen positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI 12.30-28.00) per 1,000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI 0.26-0.53) per 1,000 each month thereafter until their withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI 11.97-24.69) per 1,000 patients and continued to fall by a further 0.70 (95% CI 0.28-1.12) per 1,000 per month.

Conclusions

The introduction of financial incentives had limited success in improving rates of newly registered patients screened for higher risk drinking in England. However, their withdrawal in March 2015 saw an immediate and significant drop in recorded alcohol prevention rates: a downward trend that has continued since that point. Our findings suggest that time-limited financial incentives are unlikely to boost adoption of preventative healthcare practices in primary healthcare and may lead to adverse impacts on patients once payments are withdrawn.