Today, we’re speaking to Matt Conroy. Matt is a PhD fellow at the University of Manchester and also works for NHS Greater Manchester (ICB) as the Head of Primary Care Intelligence.

Title of paper: Impact of local enhanced incentive schemes on the performance of general practices within the United Kingdom: a systematic review

Available at: https://doi.org/10.3399/BJGP.2025.0377

Most local commissioning bodies in England, known as Integrated Care Boards (ICBs), have developed their own additional local pay-for-performance (P4P) incentive schemes alongside the Quality and Outcomes Framework (QOF). To our knowledge this is the first review to date to summarise existing evidence on the scope and effectiveness of local incentive schemes implemented in general practice in the UK with a focus on the indicators and their alignment with national schemes.

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.480 - 00:01:01.140

Hi and welcome to BJGP Interviews.

I'm Nada Khan and I'm the Senior Research Editor here at the bjgp.

Thanks for taking the time today to listen to this podcast.

Today we're talking to Matt Conroy.

Matt is a PhD fellow based at the University of Manchester and he also works for NHS Greater Manchester ICB as the Head of Primary Care Intelligence.

We're here to talk about the paper he's recently published in the bjgp, which is titled the Impact of Local Enhanced Incentive Schemes on the Performance of General Practices within the United A Systematic Review.

So, hi, Matt, it's really nice to meet you and to talk about this work and I wonder if, just to start with, if you could explain a bit about what we mean by local incentive schemes in general practice and why you wanted to look at them, and I wonder if you wanted to draw a little bit on your additional role working for the Greater Manchester ICB as well here.

Speaker B

00:01:01.220 - 00:01:54.400

Thanks.

I guess by a local deep incentive scheme, we mean something that's kind of locally designed or locally commissioned within a ICB footprint to try and address any particular population health challenges or local nuances that go over and above national policy, things like the Quality and Outcomes Framework.

I guess what was really insightful for us through doing this piece of work was actually through an FOI that we undertook.

Like 90, 98% of ICBs actually have their own local gene for incentive schemes, but we only identified 17 schemes through the published literature, the last one being from 2018.

So getting on for 10 years ago, and the fact that we know that so many ICVs are doing these things, but there's not the evidence body there, there's not the learning and sharing of best practice to really inform policy and help ICVs all try and address their local challenges.

Speaker A

00:01:55.210 - 00:02:10.650

Yeah.

And you've mentioned qof and I guess a lot of people are really familiar with qof, and as you mentioned, there are lots of local schemes sitting alongside it.

And I wonder if you have an idea of just what sort of things they're trying to incentivize, just from sort of the background to your work.

Speaker B

00:02:11.210 - 00:04:48.850

Yes.

So, as part of my day job, I help design and deliver the local GP incentive scheme in Greater Manchester.

It's roughly valued about £17 million for this year.

And I think what we try to do is use QOF as a bit of a body of evidence, but also look at a lot of our local and national data to really highlight where we think we can make a difference with these local incentive schemes.

So, for the 26, 27 financial year, we've done a piece of work to really home in on CBD and diabetes as one area, respiratory as another area, elective care.

So we can get the interface between primary and secondary care and also antimicrobial stewardship.

I think one of the things that's really fleshed out from that is the impact of non attenders on things like qof.

So through qaff, if patients have two or one invites seven days apart, they automatically get exception reported if they don't necessarily attend.

But what we found through our local data is actually there's a really strong link between those people and actually poorer CBD control and wide use of healthcare systems.

So.

So through our local GP insentive scheme, we've really designed almost a narrow cohort that looks at people's individual disease control, looking at things like blood pressure, HbA1c, but also where people haven't attended a review in more than 18 months.

So really trying to hone in on specific cohort, acknowledging that those people are really difficult to engage with by proxy.

The fact that they've had two invites and not responded.

But actually through having a local GP incentive scheme that really highlights these as a specific target cohort group and having dedicated funding alongside it, we can see that from our QOF data, we've had a reduction in exception reporting and actually it's led to these people being targeted and then we can see slow improvements in overall disease control.

So whilst it's being funneled through the local GP incentive scheme, there's this wider spillover effect in things like QOF as well.

I think that's something that we're looking to evaluate in particular and really draw out, actually, not to say that it's easy to do this exceptional reporting and we know that patients are difficult to engage with, but actually by having a really dedicated piece of work, targets these patients with the body of evidence that these are the people who are more likely to not attend their yearly GP review, but are more likely to end up using emergency care services at that point of contact, that if there's dedicated funding and almost a dedicated cohort, to say these are the people that, as an icb, we've agreed on that we really need to focus on that we can see that those improvements are being yielded and that that is actually having a secondary impact of increasing coif achievement as well.

Speaker A

00:04:49.010 - 00:05:03.310

Yeah.

So really important work, I guess, being done in local area and this review tried to bring together all of the existing evidence on this, on these different schemes.

So what did you find overall in your, in your review?

Speaker B

00:05:03.550 - 00:07:48.730

So we found overall that there was 17 schemes that have been reviewed.

Of those there was a range of different indicator types, the most of them aligning to the existing indicator types of quaff where they have a lower and upper threshold and achievement scales based on fixed cohort and payment alongside that, which isn't surprising.

And I think what surprised me is that so many of the schemes almost piggybacked off QUAFF and just gave more money for existing cough indicators, which was quite surprising in a sense of well, if quaff is already there and as well bodied there was almost that assumption, well, if we provide more money that we're going to get greater achievement on the same indicators that's already there.

I think this is the part of the, the push and pull of incentive schemes is that we're all aware that general practice has finite capacity and finite resource and there's almost an assumption that by providing more money you're going to get more outcomes.

And it's a bit crude but the analogies, it's a bit like whack a mole and that if you try and do something over here then implicitly means that something there isn't the time and dedicated effort to do something else around the system.

I think that's the real challenge with designing these schemes is that acknowledging that where there's already work that's gone in, but how do you address your local challenges and populations and that part of this might be the acceptance, that part of the money is just to give practices the time and the headspace and the workforce to deliver some of this.

I think that's one of the things that we've found really locally within our scheme that when we've scaled it up in some areas quite drastically in the first couple of years, you might not see the achievement that you want because there's a lot of time to get around these schemes, to embed them and really employ the workforce to actually start to deliver them.

I think the other thing that surprised me is that how little of them actually had an inequalities focus.

I think that's partly down to the access to data that's available.

I think through undertaking the literature review in a lot of cases people were just using aggregated EMIS extracts that just had a single denominator or numerator for an indicator.

And that's something that I think we're really keen to explore throughout the rest of my PhD and that how can we really apply a, a rigorous inequalities lens to some of this and looking at tools like the index of disparity as a way of helping us understand are we in a position where it might look on the surface like achievements going up?

And that's great, but is that because we sweep in generalization, are we actually targeting the white British affluent worried well and actually driving inequalities through having these schemes?

I think that's something we're really keen to understand because actually what you'd want to do with these schemes is that kind of holy grail of increasing the overall average, but then really reducing those inequalities and getting to a place where as much as you can and controlling for as many factors as possible, really reducing that variation across lots of different demographic groups.

Speaker A

00:07:49.050 - 00:08:02.570

Yeah.

And I guess one of the findings you found that was that some local incentive schemes seem to improve process measures.

But what did you mean by process measures and what did that actually look like in practice in the papers that you found?

Speaker B

00:08:03.290 - 00:08:22.750

So I guess by process measure we mean something like actually the recording of blood pressure, the recording of HbA1c actually taking the reading, whereas the health outcome measures, that more nuanced thing of by a bit like we see with the hypertension measures in qof, are we actually recording the blood pressure but then checking the value and seeing whether that actually has an increase or a decrease?

Speaker A

00:08:23.070 - 00:08:34.270

And I think you mentioned in the paper as well that none of the studies looked at patient reported outcomes or experiences.

Do you want to talk through that and just why that's such an important gap in the literature as well?

Speaker B

00:08:34.750 - 00:10:44.450

I think a lot of time we assume that by looking at diabetics and their HbA1C control, that good control means that patients actually have healthier lives, whereas poor control means that they don't.

I think it's an area that we're really starting to explore as an ICB about how we can use things like personal well being scores, health confidence scores, even Things like the 3 Item Loneliness Scale as a way of actually determining are we actually improving the wider health and wellbeing of a patient.

So the inference would be that if you improve their health control, that they feel more confident in their ability to manage their condition, that they understand the impact that it has on their health and well being, but that isn't a straight line.

And it might be that somebody has a yearly review, but every time they have a COPD exacerbation or they feel like they go into crisis, that they aren't confident in how they have the ability to manage their condition.

And that's when they might turn to urgent emergency care.

Is that where, well, I panic, I don't know what I need to do, therefore, I go to the nearest place that I think can deal with me.

And I guess this is something that we're trying to explore, to see if we can use these more, these measures in particular, to really understand and see if we're actually making tangible improvements.

I think for general practice, it's probably quite a different way of looking at things, but if we're truly trying to think about how we can embed things like the neighbourhood model and how we can support patients in the wider community settings, that understanding, if people actually feel like they have the confidence to manage their health better, as well as the clinical markers, that's really important because it might genuinely be that somebody goes for their yearly review, they sit down in front of somebody, they explain all this technical jargon about blood pressures and for blood counts and for a patient that doesn't actually mean anything, they want to simply know, how is my health?

Am I getting better, am I getting worse?

And these.

These measures are almost a proxy way to understand that, but almost.

Then I want to see how we can track and see if that's improving, changing in time.

And it might be then that this is where we start to bring in those wider health determinants.

And it might be that there's things like changing housing status or personal circumstances which could very easily throw somebody's health confidence off.

And that is almost a precursor to understanding whether disease control gets better or worse.

Speaker A

00:10:44.850 - 00:10:55.170

I guess there's also an interesting question about what happens when you stop paying people to do something.

And did you find any evidence about whether changes persist once an incentive is removed?

Speaker B

00:10:56.320 - 00:13:48.940

So we did manage to find one paper that considered the impact of when a local incentive scheme was removed.

And in that instance it had a lasting result.

Due to the nature of the scheme and its design.

I think more generally, across my icb, we do tend to find that there is quite a shift in that when incentivisation for a measure comes in, that we see that the focus shift onto that, but then when the payment focus is removed, that that drops off.

So a good example is that in our scheme for this year, we've introduced some rigorous DOAC monitoring that is akin to the old pcn des Measure, SMR03.

And from our data, we can very clearly see the point in which that measure was introduced as part of the PCN DES, that DOAAC monitoring really increased as soon as the SMRO3 was taken out of the PCN DES, we saw that achievement drop off and now that we've introduced that as part of our area again, that we can start to see it increase.

And I think this really speaks to the.

The finite capacity that exists within general practice and that unfortunate nature of having a local GP incentive scheme, that you will almost attract the focus to that, but by proxy you will also then detract focus from somewhere else.

I think this is the real challenge in how, when designing both national and local GP schemes, we think about the impact of having these indicators, but also how we provide some consistency to general practice and that you're not changing the indicators every year, you're constantly moving the goalposts and in some cases, by the time practice practices have just got their heads around an indicator, you're already nearly six months throughout the year.

You only then start to get the impact of those being seen, by which point, if you then remove that, you hardly get any benefits in year one of something being available.

And that's something that we're hearing loud and clear from practices in Greater Manchester and that we've had a big expansion in our scheme for this year.

And consistency is key, both in terms of actually embedding understanding, but also embedding the delivery.

But we're also conscious about how there's lots of demands and there's lots of requests for things to put into our incentive scheme and it can't be this panacea of being able to deliver all requirements that are required across health and social care.

And we need to think very carefully about how we put things into schemes.

But then if we're thinking longer term about how do we make this sustainable and long term, actually, how do we then start very slowly about thinking about potentially tapering off payments or designing the elements in such a way that address the cohorts with the greatest need, and that the longer you have one of these indicators, ideally, the cohort naturally gets smaller and smaller to the point where you then can start thinking about introducing other parts so you don't end up just flooding a scheme and you almost get back to where you start and that you have something that tries to address everything and doesn't actually address anything.

Hi and welcome to BJGP Interviews.

I'm Nada Khan and I'm the Senior Research Editor here at the bjgp.

Thanks for taking the time today to listen to this podcast.

Today we're talking to Matt Conroy.

Matt is a PhD fellow based at the University of Manchester and he also works for NHS Greater Manchester ICB as the Head of Primary Care Intelligence.

We're here to talk about the paper he's recently published in the bjgp, which is titled the Impact of Local Enhanced Incentive Schemes on the Performance of General Practices within the United A Systematic Review.

So, hi, Matt, it's really nice to meet you and to talk about this work and I wonder if, just to start with, if you could explain a bit about what we mean by local incentive schemes in general practice and why you wanted to look at them, and I wonder if you wanted to draw a little bit on your additional role working for the Greater Manchester ICB as well here.

Thanks.

I guess by a local deep incentive scheme, we mean something that's kind of locally designed or locally commissioned within a ICB footprint to try and address any particular population health challenges or local nuances that go over and above national policy, things like the Quality and Outcomes Framework.

I guess what was really insightful for us through doing this piece of work was actually through an FOI that we undertook.

So getting on for 10 years ago, and the fact that we know that so many ICVs are doing these things, but there's not the evidence body there, there's not the learning and sharing of best practice to really inform policy and help ICVs all try and address their local challenges.

Yeah.

And you've mentioned qof and I guess a lot of people are really familiar with qof, and as you mentioned, there are lots of local schemes sitting alongside it.

And I wonder if you have an idea of just what sort of things they're trying to incentivize, just from sort of the background to your work.

Yes.

So, as part of my day job, I help design and deliver the local GP incentive scheme in Greater Manchester.

It's roughly valued about £17 million for this year.

And I think what we try to do is use QOF as a bit of a body of evidence, but also look at a lot of our local and national data to really highlight where we think we can make a difference with these local incentive schemes.

So, for the 26, 27 financial year, we've done a piece of work to really home in on CBD and diabetes as one area, respiratory as another area, elective care.

So we can get the interface between primary and secondary care and also antimicrobial stewardship.

I think one of the things that's really fleshed out from that is the impact of non attenders on things like qof.

So through qaff, if patients have two or one invites seven days apart, they automatically get exception reported if they don't necessarily attend.

But what we found through our local data is actually there's a really strong link between those people and actually poorer CBD control and wide use of healthcare systems.

So.

So through our local GP insentive scheme, we've really designed almost a narrow cohort that looks at people's individual disease control, looking at things like blood pressure, HbA1c, but also where people haven't attended a review in more than 18 months.

So really trying to hone in on specific cohort, acknowledging that those people are really difficult to engage with by proxy.

The fact that they've had two invites and not responded.

But actually through having a local GP incentive scheme that really highlights these as a specific target cohort group and having dedicated funding alongside it, we can see that from our QOF data, we've had a reduction in exception reporting and actually it's led to these people being targeted and then we can see slow improvements in overall disease control.

So whilst it's being funneled through the local GP incentive scheme, there's this wider spillover effect in things like QOF as well.

I think that's something that we're looking to evaluate in particular and really draw out, actually, not to say that it's easy to do this exceptional reporting and we know that patients are difficult to engage with, but actually by having a really dedicated piece of work, targets these patients with the body of evidence that these are the people who are more likely to not attend their yearly GP review, but are more likely to end up using emergency care services at that point of contact, that if there's dedicated funding and almost a dedicated cohort, to say these are the people that, as an icb, we've agreed on that we really need to focus on that we can see that those improvements are being yielded and that that is actually having a secondary impact of increasing coif achievement as well.

Yeah.

So really important work, I guess, being done in local area and this review tried to bring together all of the existing evidence on this, on these different schemes.

So what did you find overall in your, in your review?

So we found overall that there was 17 schemes that have been reviewed.

Of those there was a range of different indicator types, the most of them aligning to the existing indicator types of quaff where they have a lower and upper threshold and achievement scales based on fixed cohort and payment alongside that, which isn't surprising.

And I think what surprised me is that so many of the schemes almost piggybacked off QUAFF and just gave more money for existing cough indicators, which was quite surprising in a sense of well, if quaff is already there and as well bodied there was almost that assumption, well, if we provide more money that we're going to get greater achievement on the same indicators that's already there.

I think this is the part of the, the push and pull of incentive schemes is that we're all aware that general practice has finite capacity and finite resource and there's almost an assumption that by providing more money you're going to get more outcomes.

And it's a bit crude but the analogies, it's a bit like whack a mole and that if you try and do something over here then implicitly means that something there isn't the time and dedicated effort to do something else around the system.

I think that's the real challenge with designing these schemes is that acknowledging that where there's already work that's gone in, but how do you address your local challenges and populations and that part of this might be the acceptance, that part of the money is just to give practices the time and the headspace and the workforce to deliver some of this.

I think that's one of the things that we've found really locally within our scheme that when we've scaled it up in some areas quite drastically in the first couple of years, you might not see the achievement that you want because there's a lot of time to get around these schemes, to embed them and really employ the workforce to actually start to deliver them.

I think the other thing that surprised me is that how little of them actually had an inequalities focus.

I think that's partly down to the access to data that's available.

I think through undertaking the literature review in a lot of cases people were just using aggregated EMIS extracts that just had a single denominator or numerator for an indicator.

And that's something that I think we're really keen to explore throughout the rest of my PhD and that how can we really apply a, a rigorous inequalities lens to some of this and looking at tools like the index of disparity as a way of helping us understand are we in a position where it might look on the surface like achievements going up?

And that's great, but is that because we sweep in generalization, are we actually targeting the white British affluent worried well and actually driving inequalities through having these schemes?

I think that's something we're really keen to understand because actually what you'd want to do with these schemes is that kind of holy grail of increasing the overall average, but then really reducing those inequalities and getting to a place where as much as you can and controlling for as many factors as possible, really reducing that variation across lots of different demographic groups.

Yeah.

And I guess one of the findings you found that was that some local incentive schemes seem to improve process measures.

But what did you mean by process measures and what did that actually look like in practice in the papers that you found?

So I guess by process measure we mean something like actually the recording of blood pressure, the recording of HbA1c actually taking the reading, whereas the health outcome measures, that more nuanced thing of by a bit like we see with the hypertension measures in qof, are we actually recording the blood pressure but then checking the value and seeing whether that actually has an increase or a decrease?

And I think you mentioned in the paper as well that none of the studies looked at patient reported outcomes or experiences.

Do you want to talk through that and just why that's such an important gap in the literature as well?

I think a lot of time we assume that by looking at diabetics and their HbA1C control, that good control means that patients actually have healthier lives, whereas poor control means that they don't.

I think it's an area that we're really starting to explore as an ICB about how we can use things like personal well being scores, health confidence scores, even Things like the 3 Item Loneliness Scale as a way of actually determining are we actually improving the wider health and wellbeing of a patient.

So the inference would be that if you improve their health control, that they feel more confident in their ability to manage their condition, that they understand the impact that it has on their health and well being, but that isn't a straight line.

And it might be that somebody has a yearly review, but every time they have a COPD exacerbation or they feel like they go into crisis, that they aren't confident in how they have the ability to manage their condition.

And that's when they might turn to urgent emergency care.

Is that where, well, I panic, I don't know what I need to do, therefore, I go to the nearest place that I think can deal with me.

And I guess this is something that we're trying to explore, to see if we can use these more, these measures in particular, to really understand and see if we're actually making tangible improvements.

I think for general practice, it's probably quite a different way of looking at things, but if we're truly trying to think about how we can embed things like the neighbourhood model and how we can support patients in the wider community settings, that understanding, if people actually feel like they have the confidence to manage their health better, as well as the clinical markers, that's really important because it might genuinely be that somebody goes for their yearly review, they sit down in front of somebody, they explain all this technical jargon about blood pressures and for blood counts and for a patient that doesn't actually mean anything, they want to simply know, how is my health?

Am I getting better, am I getting worse?

And these.

These measures are almost a proxy way to understand that, but almost.

Then I want to see how we can track and see if that's improving, changing in time.

And it might be then that this is where we start to bring in those wider health determinants.

And it might be that there's things like changing housing status or personal circumstances which could very easily throw somebody's health confidence off.

And that is almost a precursor to understanding whether disease control gets better or worse.

I guess there's also an interesting question about what happens when you stop paying people to do something.

And did you find any evidence about whether changes persist once an incentive is removed?

So we did manage to find one paper that considered the impact of when a local incentive scheme was removed.

And in that instance it had a lasting result.

Due to the nature of the scheme and its design.

I think more generally, across my icb, we do tend to find that there is quite a shift in that when incentivisation for a measure comes in, that we see that the focus shift onto that, but then when the payment focus is removed, that that drops off.

So a good example is that in our scheme for this year, we've introduced some rigorous DOAC monitoring that is akin to the old pcn des Measure, SMR03.

And from our data, we can very clearly see the point in which that measure was introduced as part of the PCN DES, that DOAAC monitoring really increased as soon as the SMRO3 was taken out of the PCN DES, we saw that achievement drop off and now that we've introduced that as part of our area again, that we can start to see it increase.

And I think this really speaks to the.

The finite capacity that exists within general practice and that unfortunate nature of having a local GP incentive scheme, that you will almost attract the focus to that, but by proxy you will also then detract focus from somewhere else.

I think this is the real challenge in how, when designing both national and local GP schemes, we think about the impact of having these indicators, but also how we provide some consistency to general practice and that you're not changing the indicators every year, you're constantly moving the goalposts and in some cases, by the time practice practices have just got their heads around an indicator, you're already nearly six months throughout the year.

You only then start to get the impact of those being seen, by which point, if you then remove that, you hardly get any benefits in year one of something being available.

And that's something that we're hearing loud and clear from practices in Greater Manchester and that we've had a big expansion in our scheme for this year.

And consistency is key, both in terms of actually embedding understanding, but also embedding the delivery.

But we're also conscious about how there's lots of demands and there's lots of requests for things to put into our incentive scheme and it can't be this panacea of being able to deliver all requirements that are required across health and social care.

And we need to think very carefully about how we put things into schemes.

But then if we're thinking longer term about how do we make this sustainable and long term, actually, how do we then start very slowly about thinking about potentially tapering off payments or designing the elements in such a way that address the cohorts with the greatest need, and that the longer you have one of these indicators, ideally, the cohort naturally gets smaller and smaller to the point where you then can start thinking about introducing other parts so you don't end up just flooding a scheme and you almost get back to where you start and that you have something that tries to address everything and doesn't actually address anything.

And I think there's potential for a real sweet spot in all of these schemes where you have just enough indicators where you get impact, but.

But not so much where you just.

Try and dilute any other main findings you want to pull out from the review that you wanted to highlight here.

I think for me, it's the health inequalities aspect of this.

That was quite surprising in that only five out of the 17 studies actually reported anything related to health inequalities.

And I think since.

I think Covid, as everybody saw, really highlighted the impact of this and it's something that I think we'd be really keen to address through my research.

And I think in gm we've been trying to do this for a long time.

I've been involved in local GP incentive schemes for over 10 years now, and that there's a huge amount of wealth of knowledge that we've built up which will exist in all other ICBs.

I think there will be evaluations that have been done internally, but.

But I think the key, like any good research, is to publicise them and share them for the wider community, because there'll be things in GM that have worked and we want to share best practice with, but the things that haven't worked as well and we'd be really keen to share that knowledge so we don't have other ICB's trying to do the same thing.

We all know how pressured both public finances are, what general practice, time and capacity is, and the last thing that the system needs is for everybody trying to be repeating the same thing over and over again, expected to different outcomes.

And if there's things that don't work or the things that we can learn from and change, then it's only right that as a system, we make those available.

Yeah, I was thinking about that when you were talking earlier about some of the successful local schemes in Manchester, and it does seem that although these schemes are designed to support local populations, there will be some lessons learned, either from positive or negative sort of experiences.

And how do you think that ICPs are best placed to share those stories so that the findings can be sort of wide, more widely known, but in a more contemporary fashion than waiting for, like, a paper to be published, which, as we know, can take some time as well.

I think this is the real challenge in that when we first started looking at our schemes, we never even thought to search in the academic literature for these things.

I think there's probably networks that we can look to set up as ICB's that we know that there's lots of kind of national local forums for things like general practice, access in general, but I think this local GP incentive scheme area is probably almost a little bit of an area that nobody's really thought about and that we know that so many ICB's are doing these, but I think there's probably some kind of forum or community of best practice where there's systems.

We then start to think about how we can publish these and make almost share the scheme documents that are available and think about how we can start to share the evaluation.

So as part of this paper I did an FOI request, which is how we got to that figure of 98% of ICBS doing these schemes.

And what was really interesting was the kind of the breadth of responses that we got back.

Some ICB just said yes, we do we have a scheme, or no we don't, and that they didn't want to share the scheme documentation because it was deemed commercially sensitive, which I understand.

But if we want to get to a place where we can truly support general practice as a kind of a wider system, we need to understand and really get to the bottom of what are the ICB's doing, how are they addressing certain challenges, what works and what doesn't work?

And I guess that's what we're trying to address through the course of my PhD, but completely acknowledging the challenge about the delay in getting things published in an academic sense.

But if there's any kind of learning and sharing that can be done in more real time, that can only be for the benefit of all ICBs.

Completely acknowledging the ICB reform that's currently going on and the challenges that that has.

But I suppose that only really supports the argument if the ICBs are losing as many staff as they are, then there's implicitly a huge amount of knowledge and experience that's also leaving.

And if we don't document these things now, that's only going to get worse in time as that people leave and that organizational knowledge and memory disappears, that it might be even in a couple of years time, somebody says, well why did we do that for a local incentive scheme?

Well, we don't know because the person who designed it and all the team who designed it left.

And that is the stage where some ICBs are at, where whole teams are just leaving, whole organizational knowledge is just disappearing.

But understanding the rationale for why things were done, such as local deep incentive schemes is really important.

And when you're trying to evaluate and you don't want to be in a position where two or three years time somebody says oh yes, let's do this, not realizing that it was tried before and didn't work because it's just the definition of insanity, isn't it?

Trying to do the same thing over and over again and expecting a different outcome.

Fair enough, yeah.

And I guess finally, given that the local incentive schemes are such a big part of primary care, what would you like commissioners and practices to think about when they're designing or evaluating them in the future?

I think when designing, I think co design is key.

And this is something that we're hearing loud and clear both in terms of actually how you formulate what it is that you want to do through a scheme, but also providing practices with the tools and resources to deliver the scheme.

So part of my role is not only supporting the design and scoping through understanding potential cohort size, it's actually doing things like building TPP searches, building monitoring dashboards.

I think things like QOF have got into a very good groove for doing that because they are nationally backed and there's national tools and resources to support those.

But for local DP incentive schemes, it's really much left up to the icbs to support delivery.

And one thing that we've heard loud and clear from practices is that we need the searches, we need the pop ups, we need the templates to support us with the coding and the identification, the patient cohorts from day one.

But we also need the tools to help us understand how we're doing our achievement, how we compare to previous years.

Because otherwise we're just setting the system up to fail when we're designing something, but not actually giving the tools to make it happen.

Really important points, I think, and I think it's really interesting getting your perspective from actually doing this on the ground as well as doing the research.

So that's a really good perspective to bring to this work, I think.

But I think that's probably a great place to wrap things up.

So I just wanted to say thanks very much for taking part today and thank you all very much for your time here and for listening to this episode of the BJGP podcast.

Matt's original research article can be [email protected] and the show notes and podcast audio [email protected] thanks again.

And by.