Intended for healthcare professionals

Analysis Measuring quality through performance

Measuring performance and missing the point?

BMJ 2007; 335 doi: (Published 22 November 2007) Cite this as: BMJ 2007;335:1075
  1. Iona Heath, general practitioner1,
  2. Julia Hippisley-Cox, professor of clinical epidemiology and general practice2,
  3. Liam Smeeth, professor of clinical epidemiology3
  1. 1Caversham Group Practice, London NW5 2UP
  2. 2Nottingham University, Nottingham NG7 2RD
  3. 3London School of Hygiene and Tropical Medicine, London
  1. Correspondence to: I Heath iona.heath{at}

    Targets do not necessarily translate into improvements for service users. Iona Heath, Julia Hippisley-Cox, and Liam Smeeth argue that performance measurement in the UK is shifting focus from what each patient needs and those who need it most

    Since April 2004, the performance of general practitioners has been measured and remunerated against a limited, although increasing, number of easily measurable clinical activities. This initiative is unique worldwide and is attracting considerable international interest. It therefore behoves us to think critically about what we are doing.

    General practitioners have responded by systematically recording the listed activities, apparently performing well above expectation, and the whole exercise has been hailed as a success for quality of care. Despite evidence that these sorts of incentives improve the quality of documentation while having a much more limited effect on underlying standards of care,1 there have undoubtedly been useful achievements. Of these, probably the most substantial are improvements in diabetic control and innovations in computer prompting systems. However, the system is in danger of missing the point of both quality and general practice.

    Treatment by numbers

    The clinical activities that are measured and rewarded by the quality and outcomes framework are largely evidence based. Nevertheless, almost all interventions cause some harm, and even when effective treatments are applied to a series of patients in clinical practice some will be harmed (although more will benefit). The risks of harm tend to increase with age, as does the potential for benefit. The stakes therefore become higher as the evidence becomes more tenuous because many trials focus on younger patients.

    Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the quality and outcomes framework, it becomes so. Mechanistic blanket management strategies, embedded into computer software, become fixed …

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