Study raises concern over 'unintended consequences' of GP reward scheme

Improvements in quality of care associated with the GP pay for performance scheme in the UK appear to have been achieved at the expense of small detrimental effects on non-incentivised aspects of care, finds a study published in the British Medical Journal today.

The findings raise important questions about the potential unintended consequences of financial incentive schemes, in particular that they could lead to neglect of non-incentivised aspects of .

Since 2004, an incentive scheme known as the Quality and Outcomes Framework (QOF), has linked one quarter of UK income to performance on a range of quality indicators.

The UK commits £1bn (€1.1bn; $1.6bn) annually in funding to the programme. Yet concerns remain about the potential unintended consequences of such schemes.

So a team of UK researchers compared changes in performance for indicators that became incentivised under the scheme with changes for indicators that did not.

Using data from the General Practice Research Database (GPRD), which contains anonymised patient records from more than 500 UK general practices, they examined trends in quality of care for 42 activities (23 incentivised and 19 non-incentivised) before and after the introduction of the scheme.

For all activities, there was a general improvement in quality prior to the introduction of financial incentives.

For incentivised activities, quality of care improved significantly in the first year of the scheme, but quickly reached a plateau in the second and third years of the scheme.

For non-incentivised activities, there was no overall effect on the rate of improvement in the first year of the scheme. However, by the third year of the scheme quality was significantly worse than projected from pre-incentive trends, possibly due to practices focusing on patients for whom rewards applied, say the authors.

These findings demonstrate some important limitations of financial incentive schemes in health care, they conclude, and the importance of monitoring – as far as possible – activities that are not incentivised, in addition to those that are, when determining the effects of such schemes.

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