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Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework

BMJ 2011; 342 doi: (Published 28 June 2011) Cite this as: BMJ 2011;342:d3590

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  1. Tim Doran, clinical research fellow1,
  2. Evangelos Kontopantelis, research associate1,
  3. Jose M Valderas, clinical lecturer2,
  4. Stephen Campbell, senior research fellow1,
  5. Martin Roland, professor of health services research3,
  6. Chris Salisbury, professor of primary healthcare4,
  7. David Reeves, senior research fellow1
  1. 1National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL, UK
  2. 2NIHR School for Primary Care Research, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF
  3. 3General Practice and Primary Care Research Unit, University of Cambridge, Cambridge CB2 0SR
  4. 4Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA
  1. Corresponding to: Tim Doran tim.doran{at}
  • Accepted 18 April 2011


Objective To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme.

Design Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included) selected from 428 identified indicators of quality of care.

Setting 148 general practices in England (653 500 patients).

Main outcome measures Achievement rates projected from trends in the pre-incentive period (2000-1 to 2002-3) and actual rates in the first three years of the scheme (2004-5 to 2006-7).

Results Achievement rates improved for most indicators in the pre-incentive period. There were significant increases in the rate of improvement in the first year of the incentive scheme (2004-5) for 22 of the 23 incentivised indicators. Achievement for these indicators reached a plateau after 2004-5, but quality of care in 2006-7 remained higher than that predicted by pre-incentive trends for 14 incentivised indicators. There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends.

Conclusions There were substantial improvements in quality for all indicators between 2001 and 2007. Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivised.


  • We are grateful for comments provided by Arnold Epstein and Meredith Rosenthal of the Harvard School of Public Health during the drafting of the paper.

  • Contributors: TD participated in the planning of the study, analysis and interpretation of data, and drafting and editing the manuscript, and is guarantor for the integrity of the data and accuracy of the data analysis. EK participated in the planning of the study, analysis and interpretation of data, and drafting and editing the manuscript. JMV, SC, CR, and DR participated in the planning of the study, analysis and interpretation of data, and editing the final manuscript. All authors saw and approved the final version of the manuscript and had full access to all of the data in the study

  • Funding: There was no direct funding for this study, but the National Primary Care Research and Development Centre receives core funding from the UK Department of Health. The views expressed are those of the authors and not necessarily those of the Department of Health. At the time of writing, TD was supported by a grant from the Commonwealth Fund as a Harkness Fellow in Health Care Policy and Practice.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; MR served as an academic advisor to the government and British Medical Association negotiating teams during the development of the UK pay for performance scheme during 2001 and 2002.

  • Ethical approval: Not required: study based on publicly available data.

  • Data sharing: Technical appendix and statistical code available from the corresponding author ( The dataset was derived from the General Practice Research Database and is not available from the authors, but it can be derived on application to GPRD.

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