Intended for healthcare professionals


The Quality and Outcomes Framework—where next?

BMJ 2013; 346 doi: (Published 07 February 2013) Cite this as: BMJ 2013;346:f659
  1. Stephen Gillam, general practitioner 12,
  2. Nicholas Steel, clinical senior lecturer in primary care 3
  1. 1Lea Vale Medical Group, Luton, UK
  2. 2Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge CB2 2SR, UK
  3. 3Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
  1. Correspondence to: S Gillam sjg67{at}
  • Accepted 8 January 2013

The UK’s pay for performance system for primary care has produced some benefits, including reducing inequalities between practices, but Stephen Gillam and Nicholas Steel argue that it is time to reduce the proportion of general practitioners’ income that it governs

Introduced in 2004, the UK Quality and Outcomes Framework (QOF) is the most comprehensive national primary care pay for performance scheme in the world.1 It includes financial incentives and information technology (computerised prompts and decision support) to achieve evidence based quality targets. The inducements are substantial, with a maximum of 1000 points available to practices, and an average payment per practice in 2011-12 of £130 (€150; $205) for each point achieved.2 Over half of these points are allocated to clinical indicators, which currently cover 22 chronic conditions, and the remainder to organisational indicators (box).

Domains of Quality and Outcomes Framework

  • Secondary prevention of coronary heart disease

  • Cardiovascular disease: primary prevention

  • Heart failure

  • Stroke and transient ischaemic attack

  • Hypertension

  • Diabetes mellitus

  • Chronic obstructive pulmonary disease

  • Epilepsy

  • Hypothyroidism

  • Cancer

  • Palliative care

  • Mental health

  • Asthma

  • Dementia

  • Depression

  • Chronic kidney disease

  • Atrial fibrillation

  • Obesity

  • Learning disabilities

  • Smoking

  • Peripheral arterial disease

  • Osteoporosis

  • Records and information

  • Information for patients

  • Education and training

  • Practice management

  • Medicines management

  • Quality and productivity

Patient experience
  • Length of consultation

Additional services
  • Cervical screening

  • Child health surveillance

  • Maternity services

  • Contraception

The QOF was designed to improve the management of chronic disease by rewarding practices for delivering interventions linked to improved health outcomes for heart disease, diabetes, and other major scourges. The money to implement the scheme was intended to raise pay for general practices. Subsequently, proposed changes have been agreed by the General Practitioners Committee of the British Medical Association and the Department of Health. Negotiations over revisions to the General Medical Services contract in England having stalled, the Department of Health recently announced that it intends to impose changes …

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