More work needed to better understand what happens when pay for performance is withdrawn, say experts

Ending performance related payments for NHS GPs in Scotland was associated with a decline in the quality of some aspects of care compared with England where financial incentives have continued, finds a study published by The BMJ today.

The researchers say further research is needed to better understand the full impact of withdrawal and the accompanying refocusing of quality improvement resources.

The NHS Quality and Outcomes Framework (QOF) pay-for-performance scheme began in 2004. It was designed to remunerate general practices for providing good quality care across a range of key areas such as cancer, diabetes, heart disease, mental health, and obesity.

In 2016, Scotland abolished the QOF to reduce the bureaucratic burden on GPs and to free-up their time for patients, but continued collecting performance data for some QOF indicators for the next three years. Researchers were therefore able to use this data to evaluate the impact of QOF withdrawal on the quality of care in Scotland compared with England over the same period.

They measured changes at one year and three years after withdrawal of QOF financial incentives in Scotland across 16 quality-of-care indicators measured annually from 2013-14 to 2018-19.

Indicators included mental health care planning, foot screening for patients with diabetes, blood pressure control in patients with underlying vascular conditions, flu vaccination and anti-clotting treatment in patients with heart disease.

Compared with England, the researchers found a significant decrease in performance for 12 of the 16 quality-of-care indicators in Scotland one year after QOF was abolished and for 10 of the 16 indicators three years after QOF was abolished.

Reductions at one year ranged from 30 percentage points for recording of mental health care planning to 3 percentage points for flu vaccination in people with heart disease.

At three years, the absolute difference between Scotland and England was largest for recording of mental health care planning (40 percentage points) and diabetic foot screening (23 percentage points).

But substantial reductions (between 10 and 20 percentage points) were also found for other outcomes such as blood pressure control in patients with vascular conditions.

No significant differences were seen between Scotland and England three years after QOF withdrawal for flu vaccination and anti-clotting treatment for heart disease patients.

The researchers acknowledge that these are observational findings with relatively few time points, and that analysis was restricted to indicators implemented in both England and Scotland in the three years April 2013 to March 2016.

The findings are, however, consistent with a published analysis of a different range of withdrawn indicators in England, and the researchers believe the results are likely to be generalisable.

As such, they say these findings are “highly relevant to designers of pay-for-performance and healthcare quality improvement programmes internationally” and they recommend that data continue to be collected for a period after the withdrawal of any indicator or performance scheme to monitor the impact.

“Changes to pay for performance should be carefully designed and implemented to monitor and respond to any reductions in care quality,” they add.

While the drop in recorded performance may be concerning, the lack of evidence for long term effectiveness and cost effectiveness of pay for performance in primary care suggests that there is as yet no need to panic, writes Kath Checkland, professor of health policy and primary care at the University of Manchester, in a linked editorial.

These findings raise some interesting questions about what quality of care means in general practice, she says, but to fully understand the benefits and harms of different approaches to quality improvement, “we must continue to collect all relevant data so the longer term effect of changes can be evaluated.”

High quality managerial support, a systematic approach to considering performance, and the provision of holistic and joined up care are all likely to be important in delivering quality improvement, she adds.


Notes for editors
Research: Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis doi: 10.1136/bmj-2022-072098
Editorial: Quality improvement in primary care doi: 10.1136/bmj.p582
Journal: The BMJ

Funding: Wellcome Trust

Link to Academy of Medical Sciences press release labelling system:

Externally peer reviewed? Yes (research); No (editorial)
Evidence type: Observational (time series analysis); Opinion
Subject: GP pay-for-performance scheme