Primary care

Intervention study to evaluate pilot health promotion payment aimed at increasing general practitioners' antismoking advice to smokers

Tim Coleman, senior lecturer ^a, Alison T Wynn, research associate ^a, Steve Barrett, research coordinator ^b, Andrew Wilson, senior lecturer ^a, Susan Adams, research associate ^c. 

^a Department of General Practice and Primary Health Care, Leicester Warwick Medical School, Leicester General Hospital, Leicester LE5 4PW, ^b Children's Brain Tumour and Disability Research Centre, Academic Division of Child Health, School of Human Development, University of Nottingham, Nottingham NG7 2UH, ^c Division of Cardiology, Department of Medicine, University of Leicester, Leicester LE3 9QP

Correspondence to: T Coleman tjc3{at}le.ac.uk

Since 1990, the UK government has tried to influence health promotion activity by general practitioners through payment schemes.¹ These have never been rigorously evaluated.² We examined the feasibility and effectiveness of a payment scheme that aimed to increase general practitioners' antismoking advice in an uncontrolled before and after study.

	Participants, methods, and results

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The health promotion payment was piloted in a deprived area of Leicester. The recruitment of practices is described elsewhere.³ Thirty five general practitioners (out of 62 approached) from 13 general practices (out of 28 approached) were recruited, and 31 participated in the study.

Before data collection began, we invited all members of primary healthcare teams to attend training in methods of stopping smoking. We then observed normal clinical behaviour over nine months (the control period). In the following nine months (the intervention period), practices could claim £15 from the health authority for identifying each patient who had smoked during the past year but was currently not smoking and had not done so for at least three months. We estimated that individual general practitioners could claim between £285 and £1125 annually.

We needed to recruit 904 smokers to measure a 10% absolute change in the proportion of smokers receiving antismoking advice from their general practitioner, with 80% power at a 5% significance level. A research assistant asked all patients (parents or guardians of those <16 years) attending a random selection of general practitioners' surgeries to complete a questionnaire before the consultation. This sought sociodemographic details, identified regular smokers (those smoking on, at least, most days), and asked about smoking behaviour and smoking related problems. Smokers were asked to complete a second questionnaire after the consultation, asking whether they had been given antismoking advice. Patients who could not complete the questionnaires were excluded. We compared the researcher's records with those of receptionists to estimate the number of missed patients.

We compared the proportions of regular smokers who recalled discussion of smoking with their general practitioners before and after introduction of payments using the Mann-Whitney U test and allowing for clustering of data.

The table shows that patients in the intervention group were older and more motivated to stop smoking than those in the control group but that the distribution of smoking related problems was similar in both groups. We found no significant difference in the proportion of smokers recalling general practitioners' antismoking advice before and after introduction of the payment.

The numbers of smokers seen by each general practitioner (cluster size) varied greatly, and the proportions of smokers recalling antismoking advice were not normally distributed (intercluster correlation coefficient for recall of antismoking advice=0.052). Fourteen doctors made no claims, 15 made one to nine claims, and four made over 10.

	Comment

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Paying general practitioners to identify smokers who had stopped smoking for three months or more did not make them give antismoking advice more frequently. The reasons behind the failure of the payments to change behaviour are explored elsewhere.³

Our findings could have been influenced by external factors, and offering smoking cessation training before the study started may have increased the amount of advice given during the control period.⁴ This would make it difficult to detect a small effect of the payment. Differences between the control and intervention groups at baseline are unlikely to account for our findings.⁵ We have no evidence to argue for a cluster randomised control trial of this payment scheme.

We have shown that it is feasible to investigate the introduction of a general practice health promotion payment in a prospective, experimental study. Future payment schemes can and should be evaluated using experimental methods.

	Acknowledgments

We thank Margaret Whatley for secretarial help and Keith Stevenson and Toby Gosden for commenting on earlier versions of this paper. We also thank Tina Booth and Jane Roberts, who provided health promotion training, and Leicestershire Health, especially Iain Harkess and Clifford Hughes, who helped complete the main study. Finally, we wish to thank the 13 practices that participated in the study and Orest Mulka, who had the original idea for the health promotion payment.

Contributors: TC and AW obtained funding for the study. ATW and SB collected data and SA advised on statistical analysis. TC wrote the paper and all other authors commented on drafts. TC is the guarantor.

	Footnotes

Funding: Trent NHS Executive and Medisearch.

Competing interests: None declared.

	References

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1.	Department of Health. General practice in the national health service: a new contract. London: HMSO, 1989.
2.	Giuffrida A, Gosden T, Forland F, Sergison M, Leese B, Pedersen L, et al. Target payments in primary care: effects on practice and health outcomes. In: Bero L, Grilli R, Grimshaw J, Oxman A, eds. Collaboration on effective professional practice module of the Cochrane Database of Systematic Reviews. Cochrane Library. Oxford: Update Software, 2000. CD000531.
3.	Coleman T, Wynn AT, Stevenson K, Cheater F. Qualitative study of pilot payment aimed at increasing general practitioners' antismoking advice to smokers BMJ 2001; 323: 432-435[Abstract/Free Full Text].
4.	Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation. Cochrane Database Syst Rev 2000;(2):CD000214.
5.	Coleman T, Wilson A. Factors associated with provision of anti-smoking advice by general practitioners. Br J Gen Pract 1999; 49: 557-558[Medline].

(Accepted 21 May 2001)