What drives general practitioners in the UK to improve the quality of care? A systematic literature review

Abstract

BackgroundIn the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated.Objectives(1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature.MethodsThis systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes.Results35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition.DiscussionThe majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care.ConclusionCurrent research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.

Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years

“…In addition, over the period of the study, although QOF was the most visible incentive scheme, there were multiple changes to national and local incentivization schemes which may have further impacted management and screening. [41][42][43] These occurred against a backdrop of changes in national treatment guidance recommendations via the UK National Institute for Health and Care Excellence (NICE) 26 and other programs such as the National Health Service Diabetes Prevention Programs (NHS DPP) 44 and NHS Health Check, 45 which may have also influenced management and screening. It would be beyond the scope of the current study and potentially impossible to disentangle these impacts, but these should be borne in mind when assessing the findings from the present study.…”

The primary care annual dementia review: a qualitative study of the views and experiences of service users and providers

“…Both studies commented on the variable quality of reviews with limitations around integration of other LTCs, documentation of discussions with carers, social care review, and inappropriate prescribing of antipsychotics. Previous evaluations of QOF in general suggest that ‘tick box’ exercises could lead to poorer patient experiences [8] and that QOF as a ‘pay for performance’ scheme led to dilemmas among primary care professionals as to whether to focus on income and targets, as opposed to patient-centred practice [29].…”

“…Both studies commented on the variable quality of reviews with limitations around integration of other LTCs, documentation of discussions with carers, social care review, and inappropriate prescribing of antipsychotics. Previous evaluations of QOF in general suggest that 'tick box' exercises could lead to poorer patient experiences [8] and that QOF as a 'pay for performance' scheme led to dilemmas among primary care professionals as to whether to focus on income and targets, as opposed to patient-centred practice [29]. While QOF mechanisms were paused during COVID-19 lockdowns, some remote 'check up' calls were reported by GP practices; other research has highlighted problems with such remote consultations including reduced quality and access difficulties [30,31].…”

“…QOF was introduced in 2004 and links GP financial reimbursement to organisational quality indicators. Reviews of the overall impact of QOF have found positive effects such as reduced mortality rates, better data recording, improved sociodemographic inequalities, [8] and reduction in emergency admissions [9]. Potential problems include poorer quality of care in activities that are not incentivised and poor patient experiences due to ‘tick box exercises’ [8].…”

The ‘PRICE’ of Physical Activity Referral Schemes (PARS): Stakeholders’ Recommendations for Delivering Quality Care to Patients

“…Respondents believed that incentives from the government could enhance patient access and affordability of PARS initiatives and boost the delivery of quality care for the programme's users. Therefore, an efficient use of incentives to promote PA and PARS initiatives could enhance the delivery of quality care in PARS, increase the programme's usage and potentially enhance patient health outcomes [51,52].…”