Intended for healthcare professionals


How to identify when a performance indicator has run its course

BMJ 2010; 340 doi: (Published 06 April 2010) Cite this as: BMJ 2010;340:c1717
  1. David Reeves, senior research fellow1,
  2. Tim Doran, clinical research fellow1,
  3. Jose M Valderas, clinical lecturer1,
  4. Evangelos Kontopantelis, research associate1,
  5. Paul Trueman, director, York health economics consortium2,
  6. Matt Sutton, professor of health economics3,
  7. Stephen Campbell, senior research fellow1,
  8. Helen Lester, professor of primary care4
  1. 1National Primary Care Research and Development Centre, Manchester M13 9PL
  2. 2York Health Economics Consortium, University of York, York YO10 5NH
  3. 3Health Methodology Research Group, Manchester M13 9PL
  4. 4National Institute for Health Research School for Primary Care Research, Manchester M13 9PL
  1. Correspondence to: H Lester Helen.lester{at}
  • Accepted 16 February 2010

In April 2011 eight clinical indicators will be removed from the UK Quality and Outcomes Framework. David Reeves and colleagues explain why they were chosen and suggest a rationale for future decisions

Increasing numbers of countries are using indicators to evaluate the quality of clinical care, with some linking payment to achievement.1 For performance frameworks to remain effective the indicators need to be regularly reviewed. The frameworks cannot cover all clinical areas, and achievement on chosen indicators will eventually reach a ceiling beyond which further improvement is not feasible.2 3 However, there has been little work on how to select indictors for replacement. The Department of Health decided in 2008 that it would regularly replace indicators in the national primary care pay for performance scheme, the Quality and Outcomes Framework,4 making a rigorous approach to removal a priority. We draw on our previous work on pay for performance5 6 and our current work advising the National Institute for Health and Clinical Excellence (NICE) on the Quality and Outcomes Framework to suggest what should be considered when planning to remove indicators from a clinical performance framework.

First UK decisions

The Quality and Outcomes Framework currently includes 134 indicators for which general practices can earn up to a total of 1000 points. Negotiations between the Department of Health and the BMA’s General Practitioners Committee last autumn led to an agreement to remove eight clinical indicators worth 28 points in April 2011 (table 1). The eight indicators are all process measures and reward actions such as taking blood pressure or taking blood to measure cholesterol, glucose, or creatinine concentrations for people with relevant chronic diseases. The framework rewards the action itself rather than a clinically informed response to results or intermediate outcomes such as better control of blood pressure or cholesterol …

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