The Tougher the Better: An Economic Analysis of Increased Payment Thresholds on the Performance of General Practices

Yan Feng, Ada Ma, Shelley Farrar, Matt Sutton

Research output: Contribution to journalArticlepeer-review

5 Citations (Scopus)


We investigate whether and how a change in performance-related payment motivated General Practitioners (GPs) in Scotland. We evaluate the effect of increases in the performance thresholds required for maximum payment under the Quality and Outcomes Framework in April 2006. A difference-in-differences estimator with fixed effects was employed to examine the number of patients treated under clinical indicators whose payment schedules were revised and to compare these with the figures for those indicators whose schedules remained unchanged. The results suggest that the increase in the maximum performance thresholds increased GPs' performance by 1.77% on average. Low-performing GPs improved significantly more (13.22%) than their high-performing counterparts (0.24%). Changes to maximum performance thresholds are differentially effective in incentivising GPs and could be used further to raise GPs' performance across all indicators
Original languageEnglish
Pages (from-to)353-371
Number of pages19
JournalHealth Economics
Issue number3
Early online date5 Jan 2014
Publication statusPublished - Mar 2015

Bibliographical note

This paper was carried out whilst Yan Feng was a PhD student in the Health Economics Research Unit, University of Aberdeen. The PhD was funded by the Institute of Applied Health Sciences, University of Aberdeen PhD studentship. The paper was written up when Yan was working in the Office of Health Economics (OHE). We would like to thank Luís Silva Miguel and the audience for their comments on this work during the tenth European Health Economics Workshop. We also thank Hugh Gravelle, Nancy Devlin, Stephen Morris, Marjon van der Pol, Robert Elliot and Mandy Ryan for their comments and suggestions. The Health Economics Research Unit (HERU) is funded by the Chief Scientist Office of the Scottish Government Health Directorates (SGHD). The views in this paper are those of the authors and not HERU, SGHD or OHE.


  • financial incentives
  • quality and outcomes framework
  • general practitioners


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