This site is intended for health professionals only

GP quality of care declined after QOF incentives were removed, study claims

Removing financial incentives for GPs to carry out clinical work resulted in a decline in care quality, according to a major study including nearly 3,000 practices.

Researchers from the universities of Dundee and Cambridge, along with staff from NICE, looked at 12 QOF indicators for which financial incentives were removed in 2014, and found this led to a decline in performance on quality measures.

But the BMA argued that while GP recording of care might have dropped, it did not necessarily mean actual quality of care patients received had decreased.

The findings come as NHS England has announced one quarter of QOF indicators could be scrapped following a review of the framework.

The study, published in the New England Journal of Medicine, analysed data from 2,819 English GP practices with more than 20m registered patients.

The research team carried out an analysis of observational data for 12 quality-of-care indicators for which incentives were removed and six indicators for which incentives were maintained.

They examined the differences between quality in 2013/14 when the incentives were still in place, with the year after they were removed and then three years after.

The paper said: ‘There were immediate reductions in documented quality of care for all 12 indicators in the first year after the removal of financial incentives.’

The study found that when comparing the year after with the result expected from the previous trend, there was a reduction in the documented quality of care.

The results ranged from a drop of 5.8 percentage points for smoking status to 62.3 percentage points for lifestyle counselling in patients with hypertension.

Three years following the removal of the incentives, the researchers saw that there were still significant reductions in the documented quality for all 12 indicators.

The largest reductions were in two of the three health-advice indicators – a drop of 71.6 percentage points for lifestyle counselling for patients with hypertension and 65.9 percentage points for preconception advice for patients with epilepsy.

The team noted that reductions in clinical-process measures were generally smaller – from a reduction of 9.2 percentage points for thyroid-function testing in patients with hypothyroidism, to a reduction of 37.5 percentage points for glycated hemoglobin testing in patients with serious mental illness.

In comparison, they noted there was ‘little change’ in GP performance on the six measures for which incentives were maintained.

Study lead Professor Bruce Guthrie, professor of primary care medicine at the University of Dundee, said: ‘Our research shows that removal of financial incentives is associated with an immediate decline in performance on twelve quality measures studied.

‘Although some of that decline may just be that clinicians have changed how they document the care that they give, declines in measures involving laboratory testing suggest that the removal of incentives did change the actual care delivered to patients.’

NICE associate director Mark Minchin, also from the research team, said: ‘This study suggests that, at a minimum, payers planning to remove financial incentives should monitor the quality of care after removal.

‘In doing so, they face the same conundrum involved in introducing incentives: the uncertainty about whether changes in documented quality represent true changes in patient care.’

But GP Committee prescribing and policy lead Dr Andrew Green argued that a drop in some of these indicators was anticipated, as some of the work that was  incentivised on an annual basis do not actually need to be done that often.

He said this included, for example, annual cholesterol tests in diabetes patients who are already on treatment and well controlled.

Dr Green said: ‘Decline in recording of many of these indicators was expected and often reflects personalisation of care, the evidence base for performing these interventions on an annual basis was never proven.

‘It must also be remembered that what is measured is the recording of the care and not the care itself, so the number of patients having, for example, retinal screening or convulsions, will not have changed.’

An NHS England spokesperson said: ‘This is a welcome addition to the body of evidence surrounding pay-for-performance and the results of the study are congruent with the findings of the QOF review undertaken by NHS England and published earlier this year. Responses to the review and other emerging evidence, such as this, will be used to inform ongoing GP contract negotiations on the future of QOF.’

Almost half of GPs want to see QOF – which some described a ‘toxic’ and ‘onerous’ – completely scrapped, according to a survey conducted by Pulse in October last year.


Incentives removed

  • Smoking status documented in all adults
  • Diabetes retinopathy screening documented
  • Glycated hemoglobin testing documented in patients with serious mental illness
  • Body-mass index documented in patients with serious mental illness
  • Thyroid function tested in patients with hypothyroidism
  • Cholesterol tested in patients with stroke or TIA
  • Cholesterol controlled in patients with stroke or TIA
  • Cholesterol controlled in patients with CHD
  • Patients with epilepsy documented as being seizure-free
  • Lifestyle advice documented in patients with hypertension
  • Preconception advice documented in patients with epilepsy
  • Advice about using long-acting, reversible contraceptives documented

Incentives maintained

  • Blood pressure documented in patients with serious mental illness
  • Alcohol consumption documented in patients with serious mental illness
  • Cholesterol controlled in patients with diabetes
  • Blood pressure controlled in patients with CHD
  • Blood pressure controlled in patients with stroke or TIA
  • Smoking-cessation advice documented in smokers with chronic conditions

Source: Quality of Care in the United Kingdom after Removal of Financial Incentives