This could reflect the increasing difficulty of target attainment in poorly controlled patients, say the authors. However, it may also reflect the lack of further incentive after attainment of the upper payment thresholds (the ceiling effect).

If so, they suggest that upper thresholds may need to be removed or targets made more challenging if people are to benefit.

Another important finding was that up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes were not captured in the framework assessment. This needs to be addressed to reduce health inequalities, say the authors.

Our work and that of others highlights the potential unintended consequences of the scheme and raises concerns that the quality and outcomes framework may not have been as efficient in reducing inequalities in health in diabetes as was hoped, write the authors.

Although the management of patients with diabetes has improved since the late 1990s, the impact of the pay-for-performance initiative on care is not straightforward, they conclude.

bmj