The Quality and Outcomes Framework has led to a reduction in the quality of care for activities not included in the QoF and had a negative impact on continuity of care, according to a new study.

Researchers from the National Primary Care Research and Development Centre in Manchester looked at the quality of care in 42 GP practices in 1998 and 2003, before the QoF was launched, and in 2005 and 2007 following implementation of the framework.

The analysis examined care of patients with asthma, diabetes or coronary heart disease using data extracted from medical records and data from patients’ questionnaires on access to care, continuity of care and interpersonal aspects of care.

The results, published in the New England Journal of Medicine, showed that there were significant improvements in care provided for the three major diseases between 1998 and 2007 with the rate of improvement accelerating for asthma and diabetes after the introduction of the QoF.

However the rate of improvement slowed after 2005 for all three conditions and the quality of aspects of care not associated with an incentive in the QoF declined for patients with asthma or heart disease. Continuity of care also immediately declined after the introduction of the pay-for-performance scheme and then continued at that reduced level.

The researchers concluded: “If the aim of pay for performance is to give providers incentives to attain targets, the scheme achieved that aim. There may have been unintended consequences including reductions in the quality of some aspects of care not linked to incentives and in the continuity of care.”

The researchers said that their analysis found significant differences between aspects of care that were linked to incentives and those that were not incentivised with incentivised activities continuing to improve after 2005, albeit at a slower rate than before that date.

They added: “This widening gap in quality came on top of already lower levels of care for indicators not linked to incentives.”

The researchers said it was not possible to pinpoint a reason for the considerably slower rate of improvement after 2005. They said several possible explanations included that near maximal scores had been achieved, that once initial gains had been made it was much harder to make subsequent gains or that the QoF did not reward further improvement once targets had been attained.

A fourth explanation was that GPs had sufficient income and had little personal motivation to improve performance and income further.

The authors said the changes to the QoF in 2006 including higher thresholds for maximum payments and a wider range of indicators endorsed the explanation that there was no incentive to improve care once targets had been reached.

On continuity of care, the researchers suggested that one explanation for the decline was the government focus on 48-hour access or the introduction of nurse-led clinics in many practices for the management of chronic disease.

They added: “Although this may have been an important part of improving the quality of care it may have made continuity of care harder to achieve.”

The researchers point out that while the drop in continuity of care may have been an unintended negative consequence of the QoF the scheme also brought unanticipated benefits including a reduction in health inequalities.