Influence of financial and reputational incentives on primary care performance: a longitudinal study

The Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time.

To determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme.

Observational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013.

The authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards.

Both the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from -0.121 percentage points per quality point (95% CI = -0.220 to -0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013.

In the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.