Incentives paid to GPs to improve healthcare have no effect on mortality, study finds

The UK Quality and Outcomes Framework (QOF), the world’s largest system of payment for performance in primary care, has failed to improve death rates, show the results of a study published in the Lancet.1

The study, carried out by York and Manchester Universities and the University of Michigan in the Unites States, showed no statistically significant declines in mortality associated with the chronic conditions targeted by the programme, which include cancer, diabetes, and heart disease.

In 2004 the Labour government introduced QOF across general practices in the United Kingdom. The programme increased GPs’ income by up to 25%, depending on performance on over 100 indicators of quality of care, and in its first seven years it cost the health services £5.86bn (€7.6bn; $8.6bn).

The new study compared mortality rates in countries that had implemented payment for performance programmes with those that hadn’t, in a population-level evaluation of mortality data from 1994 to 2010. Comparing QOF with 27 high income countries without payment for performance in primary care, the researchers found that QOF did not significantly change mortality for the composite outcome of chronic disorders that were targeted by QOF (difference −3.68 (95% confidence interval –8.16 to 0.80) deaths per 100 000 population) or for ischaemic heart disease (–2.21 per 100 000 (–6.86 to 2.44)), cancer (0.28 per 100 000 (–0.99 to 1.55)), or conditions not targeted by QOF (11.60 per 100 000 (–3.91 to 27.11)).

The report’s author, Tim Doran, professor of health policy at York University’s Department of Health Sciences, said, “These research results raise questions about the cost effectiveness of payment for performance in healthcare and about the best way to improve population health and life expectancy.”

Commenting on the results, Katherine Murphy, chief executive of the Patients Association, said, “GPs need to focus on all their patients and not just those patients where they can measure or record data and get paid for it.

“Giving doctors bribes to focus on a specific condition is morally wrong and ethically wrong. GPs must focus on patient care and outcomes—their priorities should not be compromised by financial incentives.”

Chaand Nagpaul, chair of the BMA’s General Practitioners Committee, told the Telegraph newspaper, “When it was first introduced, QOF did produce a useful way to enable practices to help patients to manage serious conditions such as diabetes, chronic lung conditions and heart disease.

“However, the QOF was undermined by increasing political interference which added needless paperwork and box ticking.”

The Department of Health for England confirmed that NHS England was set to undertake a review of QOF over the next year “to see how we can best manage the system for the future.”

In October Scotland announced that it would scrap QOF in 2017.2