Intended for healthcare professionals

Letters Future of Quality and Outcomes Framework

Adapting QOF to focus on wellbeing and health

BMJ 2017; 359 doi: (Published 04 December 2017) Cite this as: BMJ 2017;359:j5541
  1. James Close, research fellow1,
  2. Jose M Valderas, professor of health services and policy research2,
  3. Richard Byng, professor in primary care research1,
  4. Nicky Britten, professor in applied healthcare research3,
  5. Helen Lloyd, senior research fellow1
  1. 1Community and Primary Care Research Group, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth Science Park, Derriford, Plymouth PL6 8BX, UK
  2. 2University of Exeter Medical School, RSJ02, Smeall Building, St Luke’s Campus, Exeter EX1 2LU, UK
  3. 3Institute of Health Services Research, University of Exeter Medical School, St Luke’s Campus, Exeter EX1 2LU, UK
  1. james.close{at}

We welcome Marshall and Roland’s editorial on the Quality and Outcomes Framework (QOF) and propose some future directions.1

QOF (or its replacement) needs an expanded notion of quality of care that accounts for fundamental features of general practice that are not currently captured. This would focus on wellbeing and keeping people in good health rather than on managing specific diseases, based on a person centred approach that recognises the roles of patient empowerment and continuity of care. It should minimise burden on practices while allowing flexibility to tailor care to individuals, taking into account the complexity of organising, delivering, and monitoring care across multiple conditions.2

This could be achieved by:

  • Adapting QOF to local requirements while retaining essential indicators—“QOF lite.”3

  • A person centred evaluation framework including experiences (PREMS) and outcomes (PROMS),3 potentially enriched with practitioner experiences, organisational change, and tools to support self management and wellbeing.45

  • Reporting of contact data—including frequency, mode, and duration of consultations—and personnel providing basic assurances of care delivery while allowing clinicians to adapt care.

  • Flexible patient management and an intelligent booking system to facilitate annual reviews and promote continuity.6

Whatever shape QOF takes, the primary goal should be baseline assurances and internal intelligence for quality improvements, with freedom for practices to conduct their own audits and peer-to-peer learning. The system should use simple, easily understood metrics that provide clear warning signals and should avoid tunnel vision, gaming, and perverse incentives.



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