Research

Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis

Daniel R Morales, Mark Minchin, Evangelos Kontopantelis, et al

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj-2022-072098 (Published 22 March 2023)Cite this as: BMJ 2023;380:e072098

Abstract

Objective To determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared with England where the scheme continued.

Design Controlled interrupted time series regression analysis.

Setting General practices in Scotland and England.

Participants 979 practices with 5 599 171 registered patients in Scotland, and 7921 practices with 56 270 628 registered patients in England in 2013-14, decreasing to 864 practices in Scotland and 6873 in England in 2018-19, mainly due to practice mergers.

Main outcome measures Changes in quality of care at one year and three years after withdrawal of QOF financial incentives in Scotland at the end of the 2015-16 financial year for 16 indicators (two complex processes, nine intermediate outcomes, and five treatments) measured annually for financial years from 2013-14 to 2018-19.

Results A significant decrease in performance was observed 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, compared with England. At three years, the absolute percentage point difference between Scotland and England was largest for recording (by tick box) of mental health care planning (−40.2 percentage points, 95% confidence interval −45.5 to −35.0) and diabetic foot screening (−22.8, −33.9 to −11.7). Substantial reductions were, however, also observed for intermediate outcomes, including blood pressure control in patients with peripheral arterial disease (−18.5, −22.1 to −14.9), stroke or transient ischaemic attack (−16.6, −20.6 to −12.7), hypertension (−13.7, −19.4 to −7.9), diabetes (−12.7, −15.0 to −12.4), or coronary heart disease (−12.8, −14.9 to −10.8), and for glycated haemoglobin control in people with HbA_1c levels ≤75 mmol/mol (−5.0, −8.4 to −1.5). No significant differences were observed between Scotland and England for influenza immunisation and antiplatelet or anticoagulant treatment for coronary heart disease three years after withdrawal of incentives.

Conclusion The abolition of financial incentives in Scotland was associated with reductions in recorded quality of care for most performance indicators. Changes to pay for performance should be carefully designed and implemented to monitor and respond to any reductions in care quality.