Social Influence and General Practice Healthcare Quality Improvement in England's Quality and Outcomes Framework (QOF): Evidence from General Practitioner Movers

Quality improvement is a central concern of England's National Health Service (NHS) and healthcare systems around the world. Governments and researchers have theorised and tested several methods for improving quality in healthcare, and some interventions have produced modest success. Still, improving healthcare quality remains an elusive task. In this thesis, I focus on quality improvement in general practice. I provide an overview of the history of general practice quality initiatives within England's NHS, describe the theories and methods for testing healthcare quality improvement, and analyse the feasibility of an unexplored potential vehicle for quality improvement: social influence. In 2004, the NHS introduced the Quality and Outcomes Framework (QOF) as a pay-for-performance scheme intended to improve quality in general practice. Under this scheme, general practices earn QOF points by meeting certain preset benchmarks for quality, and at the end of the year, practices receive a portion of their compensation in proportion to their QOF point totals. I test whether social influence could feasibly have an influence on a practice's QOF point achievement. Specifically, I use a difference-in-difference approach to assess whether general practitioner (GP) moves (i.e., GPs moving from a practice with either a lower or higher QOF score relative to their destination practice) are correlated with changes in QOF score at the destination practice. I find that, in all QOF domains except patient experience, having a GP move from a better (worse) practice is correlated with an increase (decrease) in the destination practice's QOF scores. These results suggest that social influence among GPs may play a role in quality-relevant decisions among GPs. I discuss the impact these findings, if confirmed with more granular data, could have on quality improvement theory and policy.