Latest study suggests that introducing performance related pay for general practices did not provide long-term improvements in quality of care. While the initiative led to early improvements in quality of care, any gains were reversed when financial incentives were withdrawn.The findings highlight that financial incentives alone are no so called ‘magic bullet’ to improve quality of care, experts say.Pay-for-performanceThe UK Quality and Outcomes Framework (QOF) pay-for-performance programme was introduced across the NHS in 2004. It financially rewards general practices for providing high quality care across disease indicators such as cancer, diabetes, heart disease, mental health and obesity.A large number of QOF indicators were withdrawn in 2014 and Scotland abolished the scheme in 2016, giving researchers an opportunity to examine its short- and medium-term impact.University of Edinburgh researchers reviewed 11 studies on what happened to quality of care one year and three years after QOF financial incentives were introduced, and one and three years after they were withdrawn.They measured the effect of the incentives by comparing the findings with what would have happened to care quality if QOF had not been introduced.Initial improvementFinancially incentivised quality indicators did improve quality of care after one year, with an average increase of 6.1 per cent beyond what would have happened if previous trends continued.Improvement was less consistent at three years, with an average increase of just 0.7 per cent above expected levels.Recorded quality of care declined at both one year and three years after incentives were withdrawn, with average decreases of 10.7 per cent and 12.8 per cent respectively.The findings suggest that the effects of pay-for-performance programmes are often not sustained without continued financial motivation, the research team says.Mixed benefitsThe biggest changes in care quality for both introduction and withdrawal of incentives were in the recording of the processes of care, such as whether heart attack patients had a blood pressure recorded.Observed impacts were smaller for intermediate outcomes, such as whether blood pressure was well controlled in patients who had experienced a heart attack – and smaller still for treatment-related measures, like whether these patients were prescribed aspirin.For indicators that were never incentivised, quality of care was unchanged at one year but slightly worse at three years, with an average reduction of 1.9 per cent. The researchers suggest that the focus on incentivised conditions may have come at the expense of non-incentivised aspects of healthcare.The findings raise important questions about the value of pay-for-performance programmes for patients, clinicians and policy makers, experts say. There were high hopes for healthcare pay-for-performance when it was introduced, but the evidence from QOF is that although incentives focus clinicians’ and practices’ attention when introduced, they don’t appear to lead to sustained high-performance when the incentive is removed. Other quality improvement methods which focus on system change may be a more effective way to sustainably improve quality of care. Professor Bruce Guthrie Study lead, Advanced Care Research Centre, Usher Institute Cite asHo L, Mercer S W, Henderson D, Donaghy E, Guthrie B. Effect of UK Quality and Outcomes Framework pay-for-performance programme on quality of primary care: systematic review with quantitative synthesis BMJ 2025; 389 :e083424 doi:10.1136/bmj-2024-083424Further informationRead the study in The BMJ Publication date 26 Jun, 2025
