For immediate release
Tuesday, Sept. 6, 2006
12:01 a.m. EDT


Christopher Fleming

Under British Pay-For-Performance Initiative,
Quality Is Unexpectedly High, But So Are Payments

U.K. Would Have Proceeded More Cautiously In U.S.-Like Zero-Sum Environment, Says British Health Services Expert Martin Roland

Bethesda, MD -- The first results from the world’s most ambitious pay-for-performance (P4P) scheme, the United Kingdom’s Quality and Outcomes Framework (QOF) for general practitioners (GPs), are the focus of Robert Galvin’s interview with leading U.K. health services researcher Martin Roland, published today on the Health Affairs Web site.

The good news: Performance by the U.K.’s general practitioners was far better than expected.

The bad news: Performance by the U.K.’s general practitioners was far better than expected -- and the U.K.’s local health authorities had to pay for all that good performance.

“I think the response has been, to some extent, dismay by health authorities because the amount they’ve needed to pay over the budgeted amount is essentially unplanned-for,” says Roland, an adviser to the QOF and director of the National Primary Care Research and Development Center at England’s University of Manchester. For the first year of the QOF, GPs scored a mean of 91 percent compliance with clinical guidelines. That translated into $700 million in additional physician payments, above and beyond the $1.8 billion in new money -- representing a 20 percent increase in the U.K.’s National Health Service family practice spending and 30 percent of GPs’ incomes -- already budgeted for the QOF.

Not surprisingly, according to Roland, the current iteration of the QOF contains no new money, and the baseline levels against which GPs’ quality is measured have been raised.

Roland: Data Shows That Prior U.K.
Quality Improvement Efforts Worked Well

In retrospect, the reason for GPs’ high QOF scores is no mystery, Roland says. Data developed since the QOF began in April 2004 show that quality had already improved substantially over the 1998-2003 period, following the U.K.’s 1998 rollout of “a wide-ranging strategy of quality improvement.” The government’s strategy involved the development of clinical guidelines, a national inspection process, and a variety of quality improvement procedures in physicians’ offices. A range of incentives accompanied these interventions, principally nonfinancial ones such as giving physicians feedback on their performance and publicizing performance information to the medical community and -- more rarely -- to the wider public.

Because the U.K underestimated GPs’ quality levels when it set the QOF baseline, it left itself open to the charge that -- as Galvin says with Roland’s agreement -- it “has added a lot of money to the health care budget just to pay doctors for what they were doing already.” Galvin, the General Electric Company’s director of Global Health Care, points out that starting the QOF as a pilot project, or delaying payments until after a year of baseline measurements, might have averted the unexpected payouts. Roland responds: “Politicians never like piloting schemes because they need quick results.”

However, when Galvin notes that, in the U.S., P4P is seen as a zero-sum game with no new money available, Roland suggests that the British government would have proceeded far more cautiously had it been forced to implement a zero-sum P4P arrangement. In a zero-sum environment, “we would have certainly gone for a less ambitious scheme, because it would have been politically difficult to bring in that big scheme where individual physicians stood to lose a lot,” Roland says. “We would have brought it in more slowly . . . and I think that we would have certainly wanted a good idea of the baseline before we started, because otherwise, one doesn’t know that one is going to get a zero sum. We didn’t.”

Galvin: Is 91 Percent Really That Impressive?

While the first-year QOF results were unexpected and impressive in the health care world, Galvin suggests that this might say more about the health care world than the results themselves: “It always amazes me that in medicine, unlike other sectors, 91 percent compliance . . .  is considered a very good achievement,” he notes. Rewarding physicians for reaching such a modest goal “seems to me to be not asking enough from the profession.”

Galvin casts the QOF’s 91 percent compliance rate as particularly unimpressive given that physicians were allowed to “exception report” -- or factor out of the compliance equation -- patients for whom, in the physicians’ discretion, following the guidelines would be unwise or impossible. (For example, a GP might not take steps to control the cholesterol of a diabetic dying from other causes, and could not take the blood pressure of a hypertensive who did not respond to repeated notices to come in for an appointment; these patients would not be reported in that physician’s compliance statistics.) Roland observes, “There is certainly an argument that if you allow [exception] reporting, the top level should be 100 percent.”

Whether Physicians Are “Managing
To the Measure” Is Still Unknown

Roland says that the evidence was not in yet on whether the QOF had prompted physicians to pay undue attention to the indicators being measured under the program at the expense of other problems and of the patient as a whole. He said some manifestations of this could be “very subtle. Say, for example, if you come to see me with hypertension, it may just be that I’m more interested in taking your blood pressure as the first thing I do, rather than asking if you’ve had any side effects of the medication. So you might just not get around to telling me that you’re having problems with potency with the medication. It will be very hard to detect that sort of thing.”

Galvin points out that one of the ways to guard against this kind of problem is “to ask patients if they felt that there was undue emphasis on certain conditions and less view of them as a whole.” The QOF included such patient surveys but did not tie any financial consequences to them because, Roland explains, the British Medial Association “thought that the notion that physicians were essentially running a service industry where the customers’ views mattered would be quite hard for the doctors to adjust to.” However, the next iteration of the QOF will include patient surveys with financial consequences, Roland says.

You can read Galvin’s interview with Roland at


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at


©2006 Project HOPE–The People-to-People Health Foundation, Inc.