Objective To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme. Design Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included) selected from 428 identified indicators of quality of care. Setting 148 general practices in England (653 500 patients). Main outcome measures Achievement rates projected from trends in the pre-incentive period (2000-1 to 2002-3) and actual rates in the first three years of the scheme (2004-5 to 2006-7). Results Achievement rates improved for most indicators in the pre-incentive period. There were significant increases in the rate of improvement in the first year of the incentive scheme (2004-5) for 22 of the 23 incentivised indicators. Achievement for these indicators reached a plateau after 2004-5, but quality of care in 2006-7 remained higher than that predicted by pre-incentive trends for 14 incentivised indicators. There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends. Conclusions There were substantial improvements in quality for all indicators between 2001 and 2007. Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivised. Introduction Over the past two decades funders and policymakers worldwide have experimented with initiatives to change physicians’ behaviour and improve the quality and efficiency of medical care. Success has been mixed, and attention has recently turned to payment mechanism reform, in particular offering direct financial incentives to providers for delivering high quality care. In 2004 in the UK the Quality and Outcomes Framework (QOF) was introduced—a mechanism intended to improve quality by linking up to 25% of general practitioners’ income to achievement of publicly reported quality targets for several chronic conditions. Should these incentives succeed, the potential benefits for patients with the relevant conditions are considerable. Incentives might also improve general organisation of care, benefiting processes and conditions beyond those covered by the incentives. Financial incentives have several potential unintended consequences, however. For example, they might result in diminished provider professionalism, neglect of patients for whom quality targets are perceived to be more difficult to achieve, and widening of health inequalities. 7 Doctors might also focus on the conditions linked to incentives and neglect other conditions or, where certain activities are incentivised within the management of a particular condition, might neglect other activities for patients with that condition. Practices in England generally performed well on incentivised activities in the first year of the UK incentive scheme, and overall performance improved over the next two years. It is Corresponding to: Tim Doran tim.doran@manchester.ac.uk Extra material supplied by the author: Methodological appendix (see http://www.bmj.com/content/342/bmj.d3590/suppl/DC1) Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe BMJ 2011;342:d3590 doi: 10.1136/bmj.d3590 Page 1 of 12