General practice in the United Kingdom has the largest healthcare pay for performance programme in the world—the quality and outcomes framework (QOF).1 By earning the maximum number of performance indicator “points,” an average sized practice can earn about £125 000 (€185 000; $252 000) in addition to its usual sources of income. In this week's BMJ, Guthrie and colleagues discuss the effectiveness of the system in relation to the management of cardiovascular disease. They show how general practices can earn many points and extra payments without this necessarily indicating a reduction in the risk of cardiovascular disease.2

For example, a practice could receive nine points (each worth about £125) for generating a list of patients with hypertension. The completeness and accuracy of this list might be subject to external audit by the Primary Care Organisation. An extra 30 points would be earned if 90% or more of such patients have a record of risk factors (blood pressure and smoking history) in their notes, and 56 more points would be earned if 70% or more of such patients have a record of blood pressure lowered to below …