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To describe the Quality and Outcomes Framework (QOF)-one of the most ambitious pay-for-performance schemes introduced into any health system-as divisive would be an understatement. Launched in the UK in 2004 as a way of encouraging adherence to specified evidence based elements of general practice care, QOF has changed the nature of general practice in ways that have polarised those who work in the sector and external commentators. 1
Advocates highlight how patient care, especially for those with long term conditions, is now more structured, more systematic, and more likely to be based on high quality research evidence. They point out the rapid progress with computerisation that followed the implementation of the initiative, how better data are being used in more effective ways, and how work has been distributed more efficiently between a larger and more diverse primary care workforce. And they celebrate the extent to which these improvements have taken place across nearly every practice in the country.
Others have expressed concerns about both the intended and the unintended consequences of QOF. Critics claim that using financial incentives to focus attention on aspects of care that are easily measured has diverted attention from interpersonal elements that are less easily objectified. They say that clinical care for single diseases has been prioritised over holistic care for patients with multiple health problems. They describe how doctors have been deprofessionalised by a culture driven by computer prompts and box ticking, and how biomedical and policy agendas have been given a higher priority than what is important to patients. And they claim that the potential of QOF to incentivise continuous improvement is limited, given that many practices achieved maximum remuneration within a year of the scheme's introduction.
Has QOF worked?
Although many changes have been made to structures and working processes, a...