Intended for healthcare professionals


Going local: devolving national pay for performance programmes

BMJ 2011; 342 doi: (Published 24 January 2011) Cite this as: BMJ 2011;342:c7085
  1. Christopher Millett, senior lecturer in public health1,
  2. Azeem Majeed, professor of primary care1,
  3. Christopher Huckvale, clinical research fellow2,
  4. Josip Car, director of e-health unit1, director 3
  1. 1Department of Primary Care and Public Health, Imperial College London, London, UK
  2. 2Medical Directorate, NHS Hammersmith and Fulham, London
  3. 3Clinical Programme Group Interventional Public Health, Imperial College Academic Health Sciences Centre, London
  1. Correspondence to: C. Millett c.millett{at}
  • Accepted 5 October 2010

The recommendation that part of the Quality and Outcomes Framework be devolved to local areas has not been widely implemented. However, the experience of Christopher Millett and colleagues shows that it can help focus attention on local health needs

International evidence underlines the importance of high quality primary care in achieving an effective, efficient, and equitable health system and in improving population health.1 2 This evidence has led governments in many countries to increase their investment in primary care and introduce initiatives to improve quality, such as greater use of electronic patient records and decision support, clinical audit, greater performance monitoring and, more recently, pay for performance.3 4 5

The UK has embarked on an ambitious quality improvement effort since the late 1990s. An important part of this was the introduction of the world’s largest pay for performance programme, the Quality and Outcomes Framework (QOF), which was implemented nationally as part of a new general practitioner contract in April 2004. The framework links 25% of general practice income to achievement on 134 quality indicators and primarily aims to strengthen secondary prevention of common chronic conditions such as diabetes and stroke. Although the framework may have improved and standardised many incentivised aspects of care,6 7 8 the quality of primary care in the UK remains variable,9 and the NHS review High Quality Care For All5 signalled a strong desire by the last government to enhance the programme. The review recommended greater emphasis on prevention in QOF; fewer process (and more outcome) quality indicators; that indicator development be better informed by evidence of clinical effectiveness; and that part of the programme’s budget should be devolved to local primary care organisations. The last recommendation has proved controversial and is yet to be widely implemented.

A consultation on the …

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