The Tougher the Better: The Effect of GP Performance Thresholds in Scotland

General Practitioners (GPs) in the NHS are paid based on a mix of factors, including a pay-for-performance element, the Quality and Outcomes Framework (QOF), which was introduced in 2004. QOF rewards GPs based on performance on specific indicators.

Yan Feng

 

General Practitioners (GPs) in the NHS are paid based on a mix of factors, including a pay-for-performance element, the Quality and Outcomes Framework (QOF), which was introduced in 2004.  QOF rewards GPs based on performance on specific indicators. Although participation in the QOF is voluntary, it represents a key source of potential income for GPs and nearly all participate. The QOF has been criticised, however, for having produced little or no improvement in GP performance; some studies have claimed that the QOF achievement has had a negligible impact on health outcomes.

The OHE’s Yan Feng and her colleagues take a closer look at the effect of changes in the QOF in Scotland in April 2006. They state that "the principal aim of this paper is to evaluate the effect of an increase in the maximum performance threshold in the QOF scheme on the performance of GPs in Scotland."  The paper also examines whether GPs responded to the incentives differently according to the level of their performance before the change.

Under the QOF, GP practices are paid according to a linear schedule between a lower and upper threshold, which varies across indicators. The indicator set was revised in 2006; new indicators were introduced, some were retired and others revised.  Moreover, minimum performance thresholds were raised from 25% to 40% for all indicators. Maximum thresholds were raised for nine clinical indicators and left unchanged for 25 other indicators for which definitions also were unchanged.  This selective change provides a unique opportunity to analyse the response of GPs by comparing the performance on indicators with an increased threshold to performance on indicators that remained the same.

“The changes in the payment threshold under the QOF scheme may have differential effects on different groups of GPs”, the authors note. The research examines whether GP practices that had initially higher and initially lower performance responded differently.  The financial incentives for low-performing GPs were strongest: unless their performance improved, the amount of potential income foregone would be even greater than before the change.  High-performing GPs would have the least incentive to change.  The study also looks at a middle group.

Data used in the analysis were provided by the Scottish government’s Information Services Division and included financial years 2005/6 and 2006/7.  In total, the data include 40,704 observations across 24 indicators.

"The principal finding of this paper,” the authors state, “is that the increased maximum performance threshold under the QOF scheme in 2006 was differentially effective in improving GPs’ performance. Overall, the effect of the policy change in 2006 improved the performance of GPs in Scotland." The research also bears out the hypothesis that incentives produced greater change among lower-performing GPs.

Download: Feng, Y., Ma, A., Farrar, S. and Sutton, M. (2012) The tougher the better: The effect of an increased performance threshold on the performance of general practitioners. Research Paper 12/02. London: Office of Health Economics.