Performance of small general practices under the UK's Quality and Outcomes Framework.

BACKGROUND Small general practices are often perceived to provide worse care than larger practices. AIM To describe the comparative performance of small practices on the UK's pay-for-performance scheme, the Quality and Outcomes Framework. DESIGN OF STUDY Longitudinal analysis (2004-2005 to 2006-2007) of quality scores for 48 clinical activities. SETTING Family practices in England (n = 7502). METHOD Comparison of performance of practices by list size, in terms of points scored in the pay-for-performance scheme, reported achievement rates, and population achievement rates (which allow for patients excluded from the scheme). RESULTS In the first year of the pay-for-performance scheme, the smallest practices (those with fewer than 2000 patients) had the lowest median reported achievement rates, achieving the clinical targets for 83.8% of eligible patients. Performance generally improved for practices of all sizes over time, but the smallest practices improved at the fastest rate, and by year 3 had the highest median reported achievement rates (91.5%). This improvement was not achieved by additional exception reporting. There was more variation in performance among small practices than larger ones: practices with fewer than 3000 patients (20.1% of all practices in year 3), represented 46.7% of the highest-achieving 5% of practices and 45.1% of the lowest-achieving 5% of practices. CONCLUSION Small practices were represented among both the best and the worst practices in terms of achievement of clinical quality targets. The effect of the pay-for-performance scheme appears to have been to reduce variation in performance, and to reduce the difference between large and small practices.