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Review ArticleSystematic Review

Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework—A Systematic Review

Stephen J. Gillam, A. Niroshan Siriwardena and Nicholas Steel
The Annals of Family Medicine September 2012, 10 (5) 461-468; DOI: https://doi.org/10.1370/afm.1377
Stephen J. Gillam
1Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, England
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  • For correspondence: sjg67@medschl.cam.ac.uk
A. Niroshan Siriwardena
2Faculty of Health, Life & Social Sciences, University of Lincoln, England
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Nicholas Steel
3Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, England
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  • Pros And Cons Of Check-lists
    En P. Fung
    Published on: 01 May 2017
  • Commentary on "Pay-for-Performance in the United Kingdom
    Douglas A. Conrad
    Published on: 18 November 2012
  • Published on: (1 May 2017)
    Pros And Cons Of Check-lists
    • En P. Fung, Medical Officer

    On the subject of protocol-driven care ("box-ticking"), questionnaires, tick-boxes, or pop-ups should be used as aide-memoire rather than rigid instruments for assessing quality of care given by doctors to patients or its use being mandatory during clinical assessments.

    Clinicians who are pressed for time or single-mindedly only interested in checking all the boxes may superficially or vaguely approach the ite...

    Show More

    On the subject of protocol-driven care ("box-ticking"), questionnaires, tick-boxes, or pop-ups should be used as aide-memoire rather than rigid instruments for assessing quality of care given by doctors to patients or its use being mandatory during clinical assessments.

    Clinicians who are pressed for time or single-mindedly only interested in checking all the boxes may superficially or vaguely approach the items in the protocol without really exploring them, while dishonest clinicians may check all the boxes without addressing the items. Either way, it is probably impossible to identify when or where such malpractice has occurred, and the patient is as good as if the protocol had not existed in the first place... yet objective evidence suggests that such clinicians have delivered their service up to standards.

    That being said, anything that is aide-memoire has the real risk of being ignored such that the consultation may miss cardinal aspects of care, amounting to medical negligence.

    Competing interests: None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (18 November 2012)
    Commentary on "Pay-for-Performance in the United Kingdom
    • Douglas A. Conrad, Professor and Director

    This systematic review by Gillam, Siriwardena, and Steel adds significantly to our collective understanding of the effects of pay-for- performance (P4P) in primary care. To my knowledge,the Quality Outcomes framework (QOF)in the UK represents the largest and most robust nationwide application of P4P in the world, and thus provides uniquely valuable insights regarding the potential positive and negative effects to be expec...

    Show More

    This systematic review by Gillam, Siriwardena, and Steel adds significantly to our collective understanding of the effects of pay-for- performance (P4P) in primary care. To my knowledge,the Quality Outcomes framework (QOF)in the UK represents the largest and most robust nationwide application of P4P in the world, and thus provides uniquely valuable insights regarding the potential positive and negative effects to be expected from a large-scale implementation of P4P.

    I will comment on specific key findings from the authors' review. First and foremost, the observation that quality of care for incentivized conditions improved in the first year of the framework more rapidly than the pre-intervention trend and then returned to pre-intervention rates of improvement is evidence in support of positive initial, but (rapidly) diminishing, marginal returns to incentive intervention. This itself is an important result, insofar as it suggests that aspects of care quality most amenable to early gains (the "low-hanging fruit") were tackled first and that later gains in other, more difficult quality domains are (and likely will be) harder to attain.

    Second and equally illuminating, given the general concerns regarding unintended consequences of P4P, non-incentivized quality indicators did not improve at rates higher than pre-incentive trends in the first two years, and actually declined relative to pre-incentive trends by 2006- 2007. Absent a control group setting, the contrast of trends in incentivized to non-incentivized indicators implies a true positive effect of P4P, while also hinting that the gains to the former quality metrics might have been achieved at the expense of the non-rewarded aspects of quality. The decline in rates of improvement for the non-incented indicators also suggests that the substantial rewards realized in response to the explicit incentives were not sufficient to invest in holding the gains. Evidently, there are no free lunches in quality improvement, as in the rest of life.

    It appears that even a sustained, large incentive program like the QOF will confront the natural tendency of humans to respond to extrinsic incentives by sub-optimizing, i.e., "looking where the light is", rather than surveying the entire landscape. This reality highlights the importance of finding the sweet spot in the size and nature of incentives - not too little to stimulate response, but not so much as to crowd out the intrinsic motivation that is critical to medical practice and so deeply embedded in the socialization of clinicians.

    The authors' systematic review also shows that, while data recording and team work improved in response to QOF, other important qualitative dimensions such as continuity of care and patient-centeredness were negatively affected. The teamwork enhancements reinforce the view of quality improvement as a team sport, and suggest the wisdom of QOF designers in choosing to incentivize the practice team, rather than either the individual or large organization. However, this careful summary of the evidence demonstrates the remaining challenge of balancing incentives with other supporting organizational mechanisms to develop a comprehensive and sustained quality improvement program.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 10 (5)
The Annals of Family Medicine
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September/October 2012
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Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework—A Systematic Review
Stephen J. Gillam, A. Niroshan Siriwardena, Nicholas Steel
The Annals of Family Medicine Sep 2012, 10 (5) 461-468; DOI: 10.1370/afm.1377

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Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework—A Systematic Review
Stephen J. Gillam, A. Niroshan Siriwardena, Nicholas Steel
The Annals of Family Medicine Sep 2012, 10 (5) 461-468; DOI: 10.1370/afm.1377
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