No evidence that financial incentives for GPs have improved health or reduced inequalities

The pay-for-performance scheme for GPs introduced in April 2004, known as the Quality and Outcomes Framework (QOF), has not resulted in improved ill-health prevention or health promotion by general practitioners, reveals new research published today.

Researchers looked at the impact of the QOF on public health and inequalities and revealed that where local practices were undertaking preventive activities, they usually pre-dated the QOF and were not a result of the incentives.

The research, based on analysis of routine data and interviews with practice and primary care trust staff, assessed the extent to which QOF has contributed to improving health in deprived areas of England.

The analysis found that:

  • while QOF has been effective in pushing practices to adopt improved approaches to secondary prevention, for example, identifying and detecting illness, it has not provided incentives to improve primary prevention and public health
  • differences in performance on QOF between the least and most deprived practices have all but disappeared in recent years; however, there is limited evidence of the direct impact QOF has made to reduce inequalities. This narrowing of the gap may be the result of practices in deprived areas becoming more organised and better at meeting the requirements of the QOF rather than having significantly improved the health of their populations
  • despite incentives within the QOF to keep a register of patients with certain chronic conditions, practices in deprived areas have not actively sought to identify new cases or reach out to patients.

Anna Dixon, director of policy at The King's Fund, who led the research, said:

'A great deal of money has been invested in providing GPs with financial incentives through the QOF. It is disappointing that we have not gained greater return on investment so far in terms of health improvement in deprived areas.

'General practice has an important contribution to make to improve public health. The development of GP commissioning provides an opportunity to improve the current system of incentives to ensure practices take responsibility for population health not just for treatment of the patients in front of them.'

The report makes a number of recommendations, including the following.

  • Future revisions to the QOF and GP contract need to provide better incentives for primary prevention, and the weighting of QOF points should be aligned to the objective of reducing health inequalities.
  • In future, pay for performance should reward population outcomes such as reductions in rates of emergency admissions.
  • Incentives should be developed which better reward practices in deprived areas for delivering care that meets the needs of excluded people, such as refugees, homeless or drug/alcohol-dependent patients;
  • Practices need to make better use of information and disease registers to reach out to individuals at risk of ill-health and find ways of providing services to those patients who are less likely to attend a practice.

The research was funded by the National Institute for Health Research Service Delivery and Organisation (NIHR SDO) programme.

Notes to editors: 

For further information or interviews, please contact The King's Fund media and public affairs office on 020 7307 2585.

(1) The research was conducted by The King's Fund together with researchers at the London School of Hygiene & Tropical Medicine.

(2) The National Institute for Health Research Service Delivery and Organisation (NIHR SDO) programme was established in 1999. It aims to improve health outcomes for people by commissioning research evidence that improves practice in relation to the organisation and delivery of health care. It also builds research capability and capacity to carry out research among those who manage, organise and deliver services, and improves their understanding of the research literature and how to use research evidence. The goal of the programme is to identify, prioritise and refine the research needs of the NHS management community. The programme commissions research that will be of great value in shaping and contributing to decision-making and in promoting the more effective use of research evidence by NHS managers.

(3) The National Institute for Health Research provides the framework through which the research staff and research infrastructure of the NHS in England is positioned, maintained and managed as a national research facility. The NIHR provides the NHS with the support and infrastructure it needs to conduct first-class research funded by the government and its partners alongside high-quality patient care, education and training. Its aim is to support outstanding individuals (both leaders and collaborators), working in world-class facilities (both NHS and university),conducting leading edge research focused on the needs of patients. www.nihr.ac.uk

  • This project was funded by the National Institute for Health Research Service Delivery and Organisation programme (project number 08/1716/207).
  • The views and opinions are those of the authors and do not necessarily reflect those of the NIHR SDO programme or the Department of Health.
  • The King's Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.

Background on QOF:

The General Medical Services contract of 2004 introduced a pay-for-performance element – the Quality and Outcomes Framework (QOF) – which rewards practices for the quality of clinical care and organisational management. The main objective of QOF was to drive up the quality of primary care.

An independent inquiry into the quality of general practice commissioned by The King's Fund recently highlighted the wide variations that persist in the quality of care provided by general practice in England. It called for a greater focus on quality improvement and the need for quality to be defined more broadly from the patient's perspective. It also called for general practice to take a wider responsibility for populations and to contribute to improvements in health and working with others to reduce inequalities. Visit The King's Fund website for more information.