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

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