Case study

Paying for performance in healthcare

The UK National Health Service adopted the Quality and Outcomes Framework in an effort to improve the quality of general practice, but has it been successful?

The issue

Over the past two decades, policymakers worldwide have experimented with a range of incentives, both financial and reputational, in an attempt to link the rewards received by physicians and other healthcare providers to quality of care.

In 2004 the UK’s National Health Service took a radical step by introducing the Quality and Outcomes Framework (QOF), which instantly increased UK family practice income by about 25 per cent dependent on practice performance on 146 quality indicators, mainly relating to the management of common chronic conditions such as asthma and diabetes.

The QOF transformed the way practices provided care and measured quality. Over 200 similar schemes have since been implemented in over 40 countries, drawing on the UK’s experiences. But has the framework improved health and saved lives?

The research

A research collaboration to investigate the impacts of physician incentive schemes was launched in 2005, linking researchers based at the University of York and colleagues based at the University of Manchester and other international partner institutions.

The aim of the research programme was to determine the impact of incentives on a wide range of quality of care and patient outcomes, including socioeconomic inequalities in these outcomes.

The analyses involved innovative applications of quasi-experimental methods, linking data sources containing information on population estimates, mortality, socioeconomic status, ethnicity, health status, local area characteristics and quality of healthcare.

The outcome

The collaboration produced over 50 peer-reviewed publications with over 2,000 citations and results have been presented to worldwide policy and academic audiences.

We found that financial incentives were generally effective at improving targeted process of care, but there were unintended negative impacts on non-incentivised activities.

The positive impacts of incentives were difficult to separate from other improvement initiatives and were often temporary, with gains lost after the withdrawal of incentives.

Furthermore, there was little evidence for sustained improved patient outcomes, for example reduced hospital admissions, suggesting that paying for performance is an inefficient means of improving quality.

Crucially, QOF did not appear to save lives - mortality rates for QOF conditions did not fall significantly faster in the UK than in comparable countries. These findings have informed the development of national quality incentive programmes, both in the UK and internationally.

Featured researcher

Tim Doran

Professor Doran's main research interests are in the fields of health policy and health inequalities, including the wider social determinants of health and the effectiveness of healthcare services.

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