Introducing performance related pay for UK general practices initially improved quality of care, but did not seem to provide lasting improvements beyond that expected by previous trends, finds a study published by The BMJ today.
And initial gains in quality seemed to reverse when financial incentives were withdrawn, say the researchers.
The UK Quality and Outcomes Framework (QOF) pay-for-performance programme was introduced across the NHS in 2004 to reward general practices for providing high quality care across a range of disease indicators such as cancer, diabetes, heart disease, mental health, and obesity.
In 2014, a large number of QOF indicators were withdrawn, and in 2016 Scotland abolished the scheme, giving researchers an opportunity to examine its short and medium term impact.
To do this, they reviewed 11 studies of the impact of introducing QOF incentives for 83 indicators and withdrawing incentives for 31 indicators at a minimum of three time points before and after QOF began.
Although the design and quality of the studies differed, their risk of bias was low.
Compared with predicted levels of quality based on prior trends, QOF incentives were associated with improvements in recorded quality of care across all indicators at one year (average increase 6.1% beyond that expected), but improvement in quality was less consistent at three years (average increase 0.7%).
In contrast, incentive withdrawal led to a decline in recorded quality of care at both one and three years (average decreases of 10.7% and 12.8%, respectively), suggesting that the effects of pay-for-performance programmes are often not sustained without continued financial motivation.
Complex process indicators, such as foot screening in patients with diabetes, had larger declines than simple process indicators (for example, blood pressure measurement), intermediate outcomes (for example, blood pressure control), and treatment indicators (for example, anti-clotting therapy).
At three years, small declines in the quality of non-incentivised care was also found, suggesting that the focus on incentivised conditions may have come at the expense of important but non-incentivised aspects of healthcare.
These are observational findings, so no firm conclusions can be drawn about cause and effect, and the authors acknowledge that they could not distinguish changes in data recording from changes in the care actually provided to patients, and that some indicators were already near maximum before incentivisation, limiting likely benefit.
Whether or how best to deploy financial incentives in primary care remains uncertain, although financial incentives may have a role for engaging practices in broader quality improvement initiatives, the study authors conclude.
These findings raise important questions about the value of pay-for-performance programmes for patients, clinicians, and policy makers, say researchers in a linked editorial.
They point out that, as health systems globally continue to grapple with the challenge of improving quality of care in an era of financial restrictions, the lessons from the QOF programme in the UK can help in developing more effective and sustainable approaches to incentivising high quality primary care.
An effective QOF programme that focuses on key clinical areas and that makes best use of developments in information technology remains essential for the NHS if we are to reduce health inequalities, increase healthcare efficiency, and improve health outcomes, they conclude.
