Impact of abolishing primary care financial incentives on selected indicators of quality-of-care in Scotland: national controlled interrupted time series analysis

Objectives: The UK Quality and Outcomes Framework (QOF) primary care scheme pays financial incentives for achieving performance targets in chronic disease and was abolished in Scotland in 2016. We determined the impact of financial incentive withdrawal in Scotland on selected recorded quality-of-care, compared to England where financial incentives continued.
Design: Interrupted time-series regression study of QOF indicator data.
Setting: General practices in Scotland and England.
Participants: People registered at general practices in Scotland and England.
Intervention: Withdrawal of QOF financial incentives in Scotland at the end of the 2015-2016 financial year.
Main outcome measures: Changes in quality-of-care at 1-year and 3-years post-abolition for 16 indicators measured annually from 2013-2014 to 2018-2019 financial years.
Results: In Scotland, performance reduced significantly compared to England on 12 of the 16 quality-of-care indicators 1-year after QOF was abolished, and on 10 of 16 indicators 3-years after abolition. At 3-years, the absolute percentage-point difference in Scotland compared to England was largest for ‘tick-box’ recording of mental health care planning (-40.2 percentage-points, 95%CI -45.5 to -35.0) and diabetic foot screening (-22.8 percentage-points, 95%CI 33.9 to -11.7). However, there were also substantial reductions for intermediate outcomes including blood pressure control in patients with peripheral arterial disease (-18.5 percentage-points, 95%CI -22.1 to -14.9), stroke (-16.6 percentage-points, 95%CI -20.6 to -12.7), diabetes (-10.4 percentage-points, 95%CI -13.0 to -7.8), coronary heart disease (-12.8 percentage-points, 95%CI -14.9 to -10.8) and hypertension (-13.7 percentage points, 95% CI -19.4 to 7.9), and for HbA1c control in diabetes (-5.0 percentage-points, 95%CI 8.4 to -1.5 for HbA1c less than 75mmol/l). There were no significant differences between Scotland and England 3-years after incentive withdrawal for treatment indicators (influenza immunisation and antiplatelet/anticoagulant treatment).
Conclusion: Removal of financial incentives in Scotland was associated with reductions in recorded quality of care for most indicators. Changes to pay-for-performance should be carefully designed and implemented to monitor and respond to any reductions in care quality.