‘Pay for Quality Improvement’ schemes: Financially Incentivising Quality Improvement Activity in Primary Care. Literature Review

Financially incentivising quality improvement (QI) activity is a novel approach that was introduced into the
English general practice Quality and Outcomes Framework (QOF) in 2019. It was not fully implemented until
2022/3 because QOF income was protected during the COVID-19 pandemic. The key novelty is that practices
receive financial reward for carrying out quality improvement activities, rather than for delivering specific
processes of care or clinical outcomes.

In practice, quality improvement in the QOF means that practices are financially incentivised for carrying out Plan-Do-Study-Act cycles according to guidance on topics set by NHS England. There is no requirement for
general practices to demonstrate that any improvement activity led to a change in clinical practice or
outcome to receive the reward.

We reviewed the international published literature on processes and outcomes of financial incentivisation of
QI activity in primary care. We identified five interventions that had been evaluated. The evaluations found
• very limited evidence that financially incentivising QI improves patient care
• modest evidence that financial incentivisation of QI is valued by practitioners: it is widely taken up,
but so is QI that is not financially incentivised
• very limited evidence that it is a better investment than other options or approaches for improving
care

Evaluation of the Australian Primary Care Collaborative Program (2004-2011), the intervention implemented
for the longest and in the largest number of practices, showed promising engagement from primary care and
some evidence of improvement in clinical measures.

The evidence that QI activity that is not financially incentivised improves patient care, professional
outcomes, and organisation and system function is much larger and more reliable but shows mixed results.
This reflects the challenges of evaluating this kind of intervention: identifying appropriate outcome
measures of behaviour and culture change at a variety of levels (patient, practitioner, organisation and
system); sustaining intervention for long enough to evaluate them; and generalising results from one study
to another context.

We noted that the development of QI programmes, whether or not financially incentivised, had often not
followed best practice for the development of complex interventions. In all the studies reviewed, reporting
of the components of the interventions was limited, meaning that scaling and reproducing interventions is
challenging.

The review led us to examine the literature on enablers of effective QI. These included upfront resourcing,
professional engagement, local flexibility, leadership, shared team purpose, training and patient and public
involvement.

We recommend that quality improvement activity in primary care is designed and evaluated in line with
published complex interventions guidance with an articulated theory of change and outcome measures. If
the aim is to improve patient care, we suggest that appropriate overall resourcing and consideration of non-financial incentives may be more appropriate than financial incentivisation that is narrowly-targeted on either clinical activities and outcomes or specific improvement activities. We recommend that QI interventions focus on developing informed leadership; shared team purpose and skills; and allow topic and scope flexibility to ensure local relevance and ownership. Evaluation of QI activity must encompass multiple
levels of change needed, at patient, practitioner, organisation and system levels, and have realistic expectations of the duration of intervention need to achieve change.