A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK

Abstract

Background The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff. Methods We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers’ perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis. Results We included 18 qualitative studies that where on the providers’ perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners’ in primary care; and 4) Structural and organisational changes . Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems. Conclusions Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an ‘influencer role’ rather than being ‘responsive agents’. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.

Satisfaction of Township Hospitals Health Workers on How They Are Paid in China

“…Regarding the influence of linking income with performance on the feelings of health workers, theoretical analysis based on self-determinant theory explains that too much financial incentives could destroy intrinsic motivation and reduce the enjoyment of health workers of tasks in the long term [31,32]. Some qualitative studies found that pay-for-performance directly using financial incentive to guide the behavior of health workers was detrimental to the autonomy and professionalism of health professionals [14,15]. Though bonding income with performance could push health workers to work harder on the incentivized targets, as earning more income is a driver of health workers to make more efforts, the fatigue of efforts and pressure also decrease the utility of health workers at the same time [33].…”

“…However, how the health workers perceive and feel the PBP has been seldom studied. Some qualitative studies [14,15] found the negative consequences of PBP on feelings of health workers because PBP using financial incentives to change the medical professional behaviors is against medical professionalism and clinical autonomy.…”

Satisfaction of Township Hospitals Health Workers on Performance-based Salary in China

“…Theoretical analysis based on self-determinant theory explains that too much nancial incentives would destroy the intrinsic motivation, and reduce the the enjoy of health workers on the tasks in the long term [20,21]. Some qualitative studies found that pay-for-performance directly using nancial incentive to guide the behavior directions of health workers were detrimental to autonomy and professionalism of health professionals [22,23].…”

Diabetes in older adults – time to include frailty as a care indicator

“…These actions ensure it becomes a shared philosophy of care and action designed to improve the likelihood of benefits. Thus, the JBDS ‐ IP frailty guidance, 1 which is supported by recent national and international clinical guidance on managing frailty, 18,19 should be implemented in parallel with initiatives in primary care such as the introduction of six indicators relating to frailty within the Quality Outcomes Framework contract in the United Kingdom 20 …”

“…Thus, the JBDS-IP frailty guidance, 1 which is supported by recent national and international clinical guidance on managing frailty, 18,19 should be implemented in parallel with initiatives in primary care such as the introduction of six indicators relating to frailty within the Quality Outcomes Framework contract in the United Kingdom. 20 No one can deny the immense success of the United Kingdom-based National Diabetes Audit (NaDia) in enhancing the quality of diabetes inpatient care (such as reduced rates of medication errors, severe hypoglycaemia and inpatient occurrence of foot ulcers) 21 and the recent Getting it Right First Time initiative (GIRFT) which aims to improve diabetes care and services for all in the United Kingdom by making key recommendations in six areas including type 1 diabetes, procurement and medicines optimisation, and diabetic footcare. 22 We urge both of these initiatives and similar projects elsewhere to consider proactively to introduce frailty measures (since the presence of frailty will influence selfcare and foot care ability, hypoglycaemia incidence, insulin usage and error rates, etc) in the future work.…”