Successes and failures of pay for performance in the United Kingdom
By Martin Roland and Stephen Campbell
The New England Journal of Medicine, May 15, 2014In 2004, the United Kingdom introduced one of the world’s largest pay-for-performance programs, the Quality and Outcomes Framework. … The Quality and Outcomes Framework was originally designed in part to give family practitioners a substantial pay increase. … However, the amount of program-associated money (25% of family practitioners’ income) became increasingly regarded as a distraction, diverting their gaze onto limited parts of clinical practice and reducing the focus on the patient’s agenda during the consultation. …
In 2004, when the Quality and Outcomes Framework was introduced, much changed overnight. Family practitioners and practice staff started using full electronic medical records. …They also changed the structure and staffing of their practices in two key respects. First, there was an increase in nursing staff. … Second, there was an increase in administrative staff so that family practitioners could have rapid access to their performance… …
Over time however, the program became more intrusive into regular consultations with family practitioners. … [P]ractitioners resented constant electronic reminders of “boxes to be ticked” which led to a more biomedical focus on consultations with less attention being paid to patients’ concerns. …
Clinical care probably [italics added] improved after the introduction of the Quality and Outcomes Framework, though the effects were not compelling. …
There is clearly a problem in trying to include more and more conditions into a pay-for-performance program. … Progressively, the burden of the recording of data mounts, with consultations becoming increasing disrupted by the need to respond to requests or prompts for information.
http://www.nejm.org/doi/full/10.1056/NEJMhpr1316051
Two months ago I commented on the Medicare Payment Advisory Commission’s aimless debate about whether to alter the hazy definition of “medical home.”  I began with this question: “If you endorse a vague plan based on conventional wisdom rather than evidence and it doesn’t work, how do you revise it? Upon what evidence, by what logic, do you alter this or that part of the plan?”
Advocates of another hot managed care fad, pay-for-performance (P4P), are facing the same dilemma. The P4P fad struck the U.S. and the U.K. simultaneously in the early 2000s, approximately five years before the “medical home” fad arrived. Like “medical home” proponents, P4P proponents hyped P4P without any evidence that it would work. In an introduction to a 2006 supplement to Medical Care Research and Review devoted entirely to the emerging P4P fad, Peggy McNamara with the U.S. Agency for Healthcare Research and Quality attributed the P4P fad to the actions of “visionaries.” She then presented excerpts from nine papers which stated there is no scientific evidence for P4P (“Forward: Payment Matters?” February 2006, pp.7S-8S). The three guest editors for that supplement agreed. They stated, “P4P programs are being implemented in a near-scientific vacuum.” (Dan Berlowitz et al., “Introduction,” 10S).
The U.K.’s giant experiment with P4P is 10 years old, and the evidence indicates it is not working. It therefore presents students of the managed care movement a golden opportunity to study how movement activists cope with failure. How do you revise a P4P program that isn’t working when you had no logical or evidentiary basis for setting up the program in the first place?
The Quality and Outcomes Framework (QOF), the U.K.’s P4P scheme, was implemented in 2004 by the Tony Blair administration. The program applies to family practitioners – “half of the medical work force in the National Health Service (NHS).” Its implementation in 2004 was accompanied by a 25 percent increase in funding for primary care doctors.
The evidence that the QOF is not working is substantial. Much of that evidence is cited in the article quoted above by British experts Martin Roland and Stephen Campbell. Roland and Campbell are clearly sympathetic to the QOF. But the best they can say about this richly endowed P4P scheme is that it “probably” improved quality for patients whose care was measured, but the evidence is “not compelling,” and it might not have improved quality overall because the QOF encourages “gaming” by physicians (which may have exaggerated the apparent improvements) and has had negative side effects including “adverse effects on the quality of care for medical conditions that are not included in the incentive program” (p. 1947).
A 2012 literature review by Gillam et al. produced an even more negative assessment. Here are excerpts:
“Both groups [doctors and nurses] believed that the person-centeredness of consultations and continuity were negatively affected. Patients’ satisfaction with continuity declined, with little change in other domains of patient experience.
“Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain….. Health care organizations should remain cautious about the benefits of similar schemes.” (“Pay-for-Performance in the United Kingdom,” Annals of Family Medicine, 2012)
What do QOF proponents do now? Do they reduce the number of measures that allegedly measure quality? Do they leave the measures in place but reduce the size of the bonuses? Do they do nothing? And for any of the above, upon what basis?
If Blair and his fellow advocates of P4P had laid out a clear rationale for P4P – a diagnosis of the problem, an explanation of how P4P addresses the diagnosis, and at least some empirical evidence for their diagnosis and solution – QOF proponents might now be in a better position to adjust the QOF intelligently. But precisely because the QOF was introduced in a scientific vacuum, QOF proponents are flying blind, just as Medpac and “home” proponents are now flying blind in their attempts to redefine the “home” concept.
Those who want a firsthand sense of how blind the pilots at the QOF are should examine the QOF’s latest list of diseases and conditions that are subject to P4P. You can find them listed in the table of contents of the British Medical Association’s guide here [p. 2]. There you find 18 diseases plus “mental health,” “palliative care,” “obesity,” “smoking,” and “contraception.” Which of these categories would you like to remove? On what basis? Should we pull the “learning disability” measure because the only action required of doctors is to keep a list of patients with learning disabilities? Why was that measure put there in the first place?
Or would you like to add more measures to the existing two dozen?
If doctors were spending much of their time loafing outside their clinics listening to rock ’n’ roll music and cracking jokes, these question about which knobs on the QOF dashboard to twiddle would not be so serious. But research (never mind common sense) tells us that’s not true. Research in the U.S. indicates that doctors would need to work 22 hours a day to “deliver recommended primary care” (preventive, acute and chronic). This means that any P4P scheme imposed on primary care doctors must inevitably induce doctors to focus on “limited parts of clinical practice” and reduce their “focus on the patient’s agenda,” to quote Roland and Campbell.
Those facts – the unalterable fact that doctors simply don’t have enough time to honor all guidelines, and that P4P usurps patient authority to set their own agenda – are determinative for me. Patient autonomy (assuming the patient is of sound mind) should be the paramount value guiding all health policy.
The QOF has had 10 years to demonstrate it creates so much value that the damage it does to patient autonomy can be justified. It has not done that. The Cameron administration should pull the plug on the QOF.
Kip Sullivan, J.D., is a member of the steering committee of the Minnesota chapter of Physicians for a National Health Program. His writing has appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.