Usher Institute

Ending GP performance pay linked to care quality drop

Ending performance related payments for NHS GPs in Scotland was associated with a decline in the reported quality of some aspects of care, according to new research.

The study compared the arrangements in Scotland with England, where financial incentives have continued.


The NHS Quality and Outcomes Framework (QOF) pay-for-performance scheme began in 2004. It was designed to reimburse general practices for providing good quality care across a range of key areas such as cancer, diabetes, heart disease, mental health, and obesity.

In 2016, Scotland abolished the QOF to reduce the bureaucratic burden on GPs and to free-up their time for patients but continued collecting performance data for some QOF indicators for the next three years.

Payments stopped

The team, led by researchers from the Universities of Dundee and Edinburgh, were able to use these data to evaluate the impact of QOF withdrawal on the reported quality of care in Scotland compared with England over the same period.

They measured changes at one year and three years after withdrawal of QOF financial incentives in Scotland across 16 quality-of-care indicators measured annually from 2013 to 2014 and from 2018 to 2019.

Quality drop

Compared with England, the researchers found a significant decrease in reported performance for 12 of the 16 quality-of-care indicators in Scotland one year after QOF was abolished and for 10 of the 16 indicators three years after QOF was abolished.

Indicators included mental health care planning, foot screening for patients with diabetes, blood pressure control in patients with underlying vascular conditions, flu vaccination and anti-clotting treatment in patients with heart disease.

The researchers say further studies are required to better understand the full impact of withdrawal of financial incentives, and the impact of new primary care quality arrangements in Scotland - for  example, the creation of GP clusters where practices in a locality come together for service improvement.

Notable decreases

Reductions at one year ranged from 30 percentage points for mental health care planning to three percentage points for flu vaccination in people with heart disease.

At three years, the absolute difference between Scotland and England was largest for recording of mental health care planning - 40 percentage points - and diabetic foot screening - 23 percentage points.

Clinically important reductions - between 10 and 20 percentage points - were also found for other outcomes such as blood pressure control in patients with vascular conditions.

No significant differences were seen between Scotland and England three years after QOF withdrawal for flu vaccination and anti-clotting treatment for heart disease patients.


The researchers acknowledge that these are observational findings with relatively few time points, and that analysis was restricted to indicators implemented in both England and Scotland in the three years April 2013 to March 2016.

The findings are, however, consistent with a published analysis of a different range of withdrawn indicators in England, and the researchers believe the results are likely to be generalisable.

The findings are published in the British Medical Journal. The study team includes researchers from the National Institute for Health and Care Excellence (NICE) and the Universities of Cambridge, Dundee, Edinburgh and Manchester.

Whilst changes in performance appear to have occurred after QOF withdrawal in Scotland it is difficult to distinguish whether this was related to care not being recorded as opposed to not being delivered.

It's also important to recognise that we know that although QOF did lead to some improvement in reported quality of care when introduced, it also created risked 'crowding out', with less attention on other aspects of care which were not part of pay-for-performance. However, we were not able to examine whether abolishing QOF reduced these unintended effects of pay-for-performance.

Dr Daniel MoralesSchool of Medicine, University of Dundee

An important aspect was the foresight to collect data after QOF withdrawal, allowing the impact of changes to be evaluated and any quality improvement interventions to be based on evidence as well as opinion.

These findings are highly relevant to designers of pay-for-performance and healthcare quality improvement programmes internationally. Pay for performance is no magic bullet to improve healthcare quality, and pay for performance programme designers need to build in evaluation of impact when incentives and introduced or withdrawn. We recommend that data continue to be collected for a period after the withdrawal of any indicator or performance scheme to monitor the impact of withdrawal.

Professor Bruce GuthrieUsher Institute, University of Edinburgh

Related links

Read the research paper published in The BMJ