Quality improvement in primary care

The Quality and Outcomes Framework (QOF) pay-for-performance scheme began in the UK National Health Service in the early 2000s.1 Under a new contract, as much as 20% of general practices’ remuneration was initially tied to the achievement of performance targets. Some targets focused on the delivery of particular care (such as foot screening of patients with diabetes), whereas others tracked proxy measures for clinical outcomes (such as targets for blood pressure or diabetes control). Twenty years on it is instructive to revisit the outcomes of the scheme, and the linked paper by Morales and colleagues (doi:10.1136/bmj-2022-072098) makes use of a natural experiment to explore what happens when pay for performance ends.2

QOF has been evaluated extensively, and the benefits are modest at best.3 Achievement was high from the start,4 and, although evidence suggested the scheme led to the narrowing of some inequalities in care quality,5 longer term evaluation was disappointing. A review 10 years after the inception of QOF found initial improvements in health outcomes for …