The pay for performance incentive scheme for GPs seems to have not only reduced continuity of patient care but has also increased differences in quality between aspects of care that are included in the scheme and those that are not, suggest findings of a recent analysis.

The Department of Health rolled out the voluntary Quality and Outcomes Framework for GPs to much fanfare back in 2004, in the hope that providing payment incentives – which now account for up to 25% of practice income - to hit certain targets in a number of different clinical areas would help to boost the overall quality and achievements of primary care.

But now it seems that some potentially detrimental side effects of the scheme are emerging that are beginning to spark concern. According to an analysis by researchers at the National Primary Care Research and Development Centre in Manchester, published last week in the New England Journal of Medicine, the quality of certain aspects of primary care not included in the QOF have suffered since its introduction, most likely as a heavier focus was placed on hitting targets laid out under the scheme.

In addition, while previous analysis concluded that initial improvements were “over and above the underlying trend” following the birth of the QOF, the researchers found that in two of the three conditions studied – heart disease and asthma – these improvements reached a plateau after just 12 months, and that diabetes care continued to get better but only at the same rate as that seen prior to the scheme’s introduction.

The researchers claim that for all aspects of care — whether associated with incentives or not — and for all three conditions studied, rates of improvement in quality “slowed considerably” after 2005. This, they explain, could be because top scores had been achieved, or because after initial gains subsequent improvements were harder to achieve, or that scheme did not reward further improvements once goals were met.

Downward trend
In addition, the study found that the trend for continuity of care took a downturn after the QOF was introduced. One possible explanation, the authors claim, is that GP practices concentrated on meeting targets for rapid allowing patients access to doctors within 48 hours, which made it more difficult for patients to get an appointment with the same GP every time, disrupting the continuity of care. In addition, the growing size of many practices around the country plus the introduction of nurse-led clinics for the management of certain disease would also have made it harder to achieve continuity, they add.

The researchers conclude: “If the aim of pay for performance is to give providers incentives to attain targets, the scheme achieved that aim”, but add that “there may have been unintended consequences, including reductions in the quality of some aspects of care not linked to incentives and in the continuity of care”.