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.