Paying GPs for performance does not bring lasting clinical improvements, finds study

The introduction of QOF did not drive lasting change, say researchers who found that GP pay for performance is not a ‘magic bullet’ to improving quality.

A systematic review of studies done on the impact of QOF found that in the first year it did drive up quality of care as recorded on GP systems.

But by the third year this had not been sustained and was no better than would have been predicted by upward trends in quality happening before QOF came in in 2004, researchers reported in the BMJ.

The analysis of 11 studies also found that when QOF indicators were withdrawn as happened in Scotland in 2016, those initial gains in quality declined again.

After one year, QOF incentives were associated with an average 6.1% improvement in recorded quality of care across all indicators at one year.

But at three years this was less consistent with an average increase in 0.7% compared with what would be predicted based on previous trends.

After three years, small declines in the quality of non-incentivised care was also found, suggesting that the focus on QOF may have come at the expense of aspects of healthcare that were not incentivised.

Incentive withdrawal led to a decline in recorded quality of care at both one and three years with average decreases of 10.7% and 12.8%, respectively, the researchers reported.

It suggests that the effects of pay-for-performance programmes are often not sustained without continued financial motivation.

Overall, it means whether to have financial incentives at all or the best way to employ them if you do remains uncertain they concluded.

Lead author Professor Bruce Guthrie, professor of general practice at the University of Edinburgh said when QOF first came in quite a lot of practices were already near the maximum so it accelerated the improvement but after that there was nowhere else to go.

But it was clear that when you took the incentives away, quality goes down. Some of that may be work that is being done but not recorded, he explained.

‘It does seem to grab people’s attention, but then the question is what do you want to grab their attention on. The QOF as it was introduced in 2004 was all about very specific quality indicators for disease.

‘But the challenge that is overwhelming both general practice and hospitals is people with lots of diseases and frailty because the population is ageing quite rapidly. You have lots of conditions, polypharmacy and QOF isn’t really directed at that group at all.’

He said more recently NHS England had moved to paying for engagement with quality improvement.

‘One of the problems is that NHS England spends over £700 million a year on QOF but you can’t stop paying practices, because it’s just part of their core income, and if you took it away, they’d collapse.’

The disease focused quality improvement model of QOF had its place at a certain point in time alongside the new money for practices but ‘it doesn’t necessarily address the problems that are going to overwhelm us in the next 20 years,’ he said.

Professor Azeem Majeed, professor of primary care and public health at Imperial College London, wrote a linked editorial pointing out that the future challenge will be retaining the elements of QOF that were helpful without adding to the already significant bureaucratic load on general practice.

Speaking with Pulse he said: ‘My view is that QOF needs to evolve. The evidence suggests that financial incentives alone are often insufficient to drive lasting changes in quality of care.

‘The initial improvements seen with QOF indicators can wane over time, and a decline can also occur if incentives are withdrawn. This indicates that a simple pay-for-performance model doesn’t necessarily embed quality improvement into everyday general practice in a sustainable way.

As well as focusing on important areas such as vaccination, health inequalities and secondary prevention it should become more strategic he added.

‘QOF should be one component of a broader quality improvement system that also promotes mechanisms like greater continuity of care, fosters professional development, and addresses systemic issues like workforce shortages.’

The research comes as QOF has been steadily pared back in recent years, with large chunks income-protected to reduce workload. Around a third of indicators were effectively frozen in 2023/24 and 2024/25, and then scrapped entirely from this year. The funding was redistributed via the global sum and other payment streams, in a shift away from traditional QOF targets.