What drives general practitioners in the UK to improve the quality of care? A systematic literature review.

BACKGROUND: In the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated. OBJECTIVES: (1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature. METHODS: This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes. RESULTS: 35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition. DISCUSSION: The majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care. CONCLUSION: Current research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.

Achieving better quality care in general practice: are incentives the answer?

BACKGROUND: The introduction of financial incentives, such as the quality and outcomes framework (QOF), historically lead to improvements in standardising practice. However, with shifting demands on healthcare providers, are these schemes still enough to drive high-quality care? AIM: To explore current incentives, intrinsic and extrinsic, their role and effectiveness in improving quality of care and how they are perceived by GPs. METHOD: Mixed methods study using two systematic literature reviews including 44 papers and 18 semi-structured interviews with GPs. RESULTS: In the literature, QOF was associated with reduced socioeconomic inequalities, decreased mortality and improved outcomes. However, the absence of control groups and the simultaneous analysis of multiple indicators complicates the findings. GPs agreed with the literature and viewed financial incentives as beneficial, however, they felt the key driver in providing good-quality care was their intrinsic motivation. Financial incentives were found to contribute to depersonalised care, diluted provision of non-incentivised activities and hindered overall practice. The results from the second literature review were in keeping with the views of the participants. They illustrated the importance of managing factors contributing to physician burnout, reduced performance, and low job satisfaction, which can result in the provision of low-quality care. CONCLUSION: Financial incentives have the potential to induce behaviour change, however, their use in quality improvement is limited when used alone. If used in an environment that nurtures intrinsic motivation, healthcare providers will be more driven to achieve a higher quality of care and will be better able to cope with shifting demands.