General practice characteristics associated with pay-for-performance in the UK: a systematic review

Background The Quality and Outcomes Framework (QOF), a pay-for-performance programme, has been the most widespread quality initiative in National Health Service (NHS) general practice since 2004. It has contributed between 25% and 8% of practices’ income during this time, but concerns about its effect on equity have been raised.

Aim Understand which practice characteristics are associated with QOF performance.

Design and setting Systematic review, NHS general practice.

Method MEDLINE, Embase, CINAHL+, Web-of-Science and grey literature were searched for studies examining the association between general practice characteristics and QOF performance.

Results Twenty-two studies, published between 2006 and 2022, exploring the relationship between six population and 15 organisational characteristics and QOF measures were found. Most studies were cross-sectional, of English general practices, and used data from the early years of QOF. A negative association was frequently found between overall QOF performance and socioeconomic deprivation; proportion of registered patients>65; list size; mean general practitioner (GP) age; and Alternative Provider Medical Services contracts. Group practices (versus single-handed); more full-time-equivalent GPs; and being a training practice were frequently associated with better overall QOF performance. The associations of most other characteristics with performance were inconsistent.

Conclusion Associations with characteristics both within and outside practices’ control were identified. Pay-for-performance instruments may systematically disadvantage practices serving those at greatest risk of ill-health, such as older and more deprived populations. Given the cross-sectional design of many studies and focus on the early years of QOF, more up-to-date evidence is needed to understand if and why these relationships persist.