Effects of pay for performance on the quality of primary care in England

N Engl J Med. 2009 Jul 23;361(4):368-78. doi: 10.1056/NEJMsa0807651.


Background: A pay-for-performance scheme based on meeting targets for the quality of clinical care was introduced to family practice in England in 2004.

Methods: We conducted an interrupted time-series analysis of the quality of care in 42 representative family practices, with data collected at two time points before implementation of the scheme (1998 and 2003) and at two time points after implementation (2005 and 2007). At each time point, data on the care of patients with asthma, diabetes, or coronary heart disease were extracted from medical records; data on patients' perceptions of access to care, continuity of care, and interpersonal aspects of care were collected from questionnaires. The analysis included aspects of care that were and those that were not associated with incentives.

Results: Between 2003 and 2005, the rate of improvement in the quality of care increased for asthma and diabetes (P<0.001) but not for heart disease. By 2007, the rate of improvement had slowed for all three conditions (P<0.001), and the quality of those aspects of care that were not associated with an incentive had declined for patients with asthma or heart disease. As compared with the period before the pay-for-performance scheme was introduced, the improvement rate after 2005 was unchanged for asthma or diabetes and was reduced for heart disease (P=0.02). No significant changes were seen in patients' reports on access to care or on interpersonal aspects of care. The level of the continuity of care, which had been constant, showed a reduction immediately after the introduction of the pay-for-performance scheme (P<0.001) and then continued at that reduced level.

Conclusions: Against a background of increases in the quality of care before the pay-for-performance scheme was introduced, the scheme accelerated improvements in quality for two of three chronic conditions in the short term. However, once targets were reached, the improvement in the quality of care for patients with these conditions slowed, and the quality of care declined for two conditions that had not been linked to incentives. Continuity of care was reduced after the introduction of the scheme.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Asthma / therapy
  • Attitude to Health
  • Coronary Disease / therapy
  • Diabetes Mellitus, Type 2 / therapy
  • England
  • Family Practice / economics
  • Family Practice / standards*
  • Humans
  • Linear Models
  • Outcome and Process Assessment, Health Care
  • Physician Incentive Plans*
  • Primary Health Care / economics
  • Primary Health Care / standards*
  • Quality of Health Care / economics
  • Quality of Health Care / trends*
  • Reimbursement, Incentive
  • State Medicine