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Doctor Behaviour Under a Pay for Performance Contract: Evidence from the Quality and Outcomes Framework


  • Hugh Gravelle

    (National Primary Care Research & Development Centre, Centre for Health Economics, University of York)

  • Matt Sutton

    (Health Economics Research Unit, University of Aberdeen)

  • Ada Ma

    (Health Economics Research Unit, University of Aberdeen)


Since 2003, 25% of UK general practitioners’ income has been determined by the quality of their care. The 65 clinical quality indicators in this scheme (the Quality and Outcomes Framework) are in the form of ratios, with financial reward increasing linearly with the ratio between a lower and upper threshold. The numerator is the number of patients for whom an indicator is achieved and the denominator is the number of patients the practices declares are suitable for the indicator. The number declared suitable is the number of patients with the relevant condition less the number exception reported by the practice for a specified range of reasons. Exception reporting is designed to avoid harmful treatment resulting from the application of quality targets to patients for whom they were not intended. However, exception reporting also gives GPs the opportunity to exclude patients who should in fact be treated in order to achieve higher financial rewards. This is inappropriate use of exception reporting or ‘gaming’. Practices can also increase income if they are below the upper threshold by reducing the number of patients declared with a condition (prevalence), or by increasing reported prevalence if they were above the upper threshold. This study examines the factors affecting delivered quality (the proportion of prevalent patients for indicators were achieved) and tests for gaming of exceptions and for prevalence reporting being responsive to financial incentives.

Suggested Citation

  • Hugh Gravelle & Matt Sutton & Ada Ma, 2007. "Doctor Behaviour Under a Pay for Performance Contract: Evidence from the Quality and Outcomes Framework," Working Papers 028cherp, Centre for Health Economics, University of York.
  • Handle: RePEc:chy:respap:28cherp

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    References listed on IDEAS

    1. Mark Dusheiko & Hugh Gravelle & Rowena Jacobs & Peter C Smith, "undated". "The Effect of Budgets on Doctor Behaviour: Evidence From A Natural Experiment," Discussion Papers 03/04, Department of Economics, University of York.
    2. Wagstaff, Adam & van Doorslaer, Eddy, 2000. "Chapter 34 Equity in health care finance and delivery," Handbook of Health Economics,in: A. J. Culyer & J. P. Newhouse (ed.), Handbook of Health Economics, edition 1, volume 1, chapter 34, pages 1803-1862 Elsevier.
    3. Morris, Stephen & Sutton, Matthew & Gravelle, Hugh, 2005. "Inequity and inequality in the use of health care in England: an empirical investigation," Social Science & Medicine, Elsevier, vol. 60(6), pages 1251-1266, March.
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    Cited by:

    1. Grant Miller & Kimberly Singer Babiarz, 2013. "Pay-for-Performance Incentives in Low- and Middle-Income Country Health Programs," NBER Working Papers 18932, National Bureau of Economic Research, Inc.
    2. Tsiachristas, Apostolos & Dikkers, Carolien & Boland, Melinde R.S. & Rutten-van Mölken, Maureen P.M.H., 2013. "Exploring payment schemes used to promote integrated chronic care in Europe," Health Policy, Elsevier, vol. 113(3), pages 296-304.
    3. Tsiachristas, Apostolos & Dikkers, Carolien & Boland, Melinde R.S. & Rutten-van Mölken, Maureen P.M.H., 2016. "Impact of financial agreements in European chronic care on health care expenditure growth," Health Policy, Elsevier, vol. 120(4), pages 420-430.

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    Quality. Incentives. Gaming. Pay for performance.;

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