Dumping elements of the Quality and Outcomes Framework – an annual incentive and reward scheme for GPs – could have a negative effect on patient care, according to a study published in the British Medical Journal.

The (previous) government launched the QOF back in 2004, on the promise that enabling doctors to earn extra cash for hitting predefined targets in five main groups of indicators - ranging from clinical areas, such as heart disease, to patient experience, such as consultation length - would help to boost the quality of primary care services.

But last year, the decision was taken by the Department of Health that indicators would removed from the scheme regularly, and consequently it has been agreed that eight clinical indicators will be scrapped from the QOF next year.

As a team of researchers led by Helen Lester from the NIHR School for Primary Care Research, Manchester, note in the BMJ, much work has been carried out on determining the impact the introduction of financial incentives might have on performance, but there is little data on how their subsequent removal could ultimately affect patient care.

Their research - which centred on Kaiser Permanente clinics in California, where an incentive reward scheme has been in place for some time - suggest there is a danger that the removal of incentives could have a detrimental affect on primary care services, and if this finding holds true it could have significant implications for future policy decisions.

For example, looking at retinopathy screening, during a five-year period in which incentives were put in place rates of screening climbed from 84.9% to 88.1%, but, conversely, over a subsequent four-year timeframe in which these incentives were taken away screening rates dropped every year to 80.5%.

A similar picture was observed with the number of patients undergoing cervical screening, which inched up from 77.4% to 78.0% in the first two years after the introduction of incentives, then fell again over a five year period in which they were removed to 74.3%, only to rise again following their re-introduction.

While the researchers concede that there are limitations to the study – the obvious one being that, at Kaiser Permanente, clinical incentives are directed towards medical facilities as opposed to individual doctors - they stress that if the findings of their study are found to be consistent over a wider range of indicators, “clinicians need to be aware that if financial incentives are removed, their focus may change and they may need to think proactively about how to maintain previous levels of patient care”.

Continuity of care?
However, they also note that a dip in performance in one area may “may be more than offset by improvements in care in a different clinical area to which incentives are shifted”.

Indeed, according to a recent analysis by researchers at the National Primary Care Research and Development Centre in Manchester, a downside of the pay for performance incentive scheme for GPs in the UK seems to be a reduction in continuity of patient care, and increasing differences in quality between aspects of care that are included in the scheme and those that are not.

In addition, the researchers found that in two of the three conditions they looked at – heart disease and asthma – improvements related to the QOF reached a plateau after just 12 months, highlighting the potential limitations of the scheme, which costs the UK around £1 billion a year.