Intended for healthcare professionals

Letters Quality and Outcomes Framework

End the cycle of ignorance—a moral imperative to evaluate the effects of QOF

BMJ 2018; 361 doi: (Published 11 June 2018) Cite this as: BMJ 2018;361:k2544
  1. Tom Marshall, professor of public health and primary care
  1. University of Birmingham, Birmingham B15 2TT, UK
  1. t.p.marshall{at}

The Quality and Outcomes Framework (QOF) was introduced without proper evaluation of its effects. It has been abolished in Scotland and may be slimmed down in England without proper evaluation of its effects.1 This cycle of ignorance is unfortunately typical in health policy. It is frankly immoral to conduct policy in this way. Because data collection is integral to QOF it lends itself to evaluation.

If QOF incentives are to be withdrawn for some indicators they should be withdrawn in general practices in some geographical areas and not in others—a cluster randomised controlled trial design. Data should continue to be collected on all indicators in general practices continuing under QOF and in general practices moving to a new system. This would allow the effects of QOF withdrawal to be evaluated. At the end of this process we would have better information on which to make a decision.

I suspect that this will not happen. Policy makers pretend to know that a policy works. Then they pretend to know it does not work. But the truth is that we don’t know.


  • Competing interests: None declared.


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