Questions over the effectiveness of the GP pay-per-performance scheme in England have bubbled to the surface again following research published in the British Medical Journal assessing its affect on the care of hypertension.

The Quality and Outcomes Framework incentive scheme was launched in 2004 with the hope that enabling doctors to earn extra cash for achieving preset targets in five main groups of indicators - such as clinical areas and patient experience - would boost the quality of primary care services. 

The scheme costs the National Health Service more than £1.8 billion a year, but evidence of its clinical effectiveness is still thin on the ground. 

Researchers from the UK, US and Canada looked at blood pressure monitoring and treatment intensity both before and after the introduction of QOF, but they found that paying for performance actually made no difference to the rates of stroke, heart attack, heart failure, or all cause mortality, largely because targets were already being achieved or close to it before its implementation.

They conclude that generous financial incentives, such as those offered by the QOF, "may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions".

"We found that the quality of care for hypertension was improving and already close to the threshold set for maximum payment in the pay for performance initiative," explained lead author Brian Serumaga, adding that "performance thresholds may have been set too low for the financial incentives to be effective".

But defending the QOF, Laurence Buckman, chairman of the British Medical Association’s GPs Committee, stressed that it is much more than simply an incentive scheme, designed to ensure that patients get high quality care no matter where they live.

True gains

Moreover, he argues that the scheme is still relatively new, and its true gains will only be seen in the long term as the body of evidence grows. Even so, "other studies have shown that it has improved care and treatment for people with diabetes and reduced the number of heart attacks and deaths, particularly in deprived areas," he noted. 

In addition, research published in the BMJ last year - which looked at Kaiser Permanente clinics in California, where an incentive reward scheme has been in place for some time - has also warned that dumping elements of QOF could have a negative effect on patient care.

The Department of Health said the current payment scheme for GPs will be reformed as QOF and other incentives are insufficiently focused on patient outcomes.