Quality and Outcomes Framework: time to take stock.

We are now living in the seventh annual cycle of the Quality and Outcomes Framework (QOF). So ingrained has QOF become for everyone working in UK primary care, that it is hard to imagine life before QOF. It is hard too, to recall the revolutionary changes that accompanied its arrival. Prior to QOF, there were just two targets for general practice in the UK: childhood immunisations and cervical smears. Suddenly, on 1 April 2004, along came targets for 147 indicators. Initially, 76 of these were clinical targets covering 10 long-term conditions. These were revised in 2006 to 80 targets covering 19 long-term conditions. Implementation occurred within a cultural context which it is important to review when considering future directions for QOF. The story of the precursors and prerequisites of QOF has already been well told. 1 In the time leading up to the arrival of QOF, there was public concern about the poor quality of public services, a growing culture of public sector accountability, acceptance that the NHS was underfunded when compared with other European countries, increasing dissemination of information from the evidence-based medicine movement, and a backdrop of economic growth accompanied by the political will to invest in public services. These factors combined with something of a crisis in primary care: GP recruitment was at an all-time low and a substantial boost to GP income was offered, with QOF as the vehicle. QOF was implemented as a pay-for-performance (P4P) system, structured so that it contained evidence-based indicators and was weighted according to the anticipated workload demands that each indicator would place on an average general practice. The achievements of QOF have been considerable. It is undoubtedly the most comprehensive, far-reaching P4P system in the world. It has demonstrated high median levels (far higher than originally predicted) of primary care quality achievement, with further annual increases in reported achievement. Consistent improvements have been recorded for 'intermediate outcomes' such as blood pressure, cholesterol, and glycated haemoglobin control. Secondary prevention has been promoted in the form of aspirin for patients with cardiovascular disease, and angiotensin-converting enzyme inhibitors plus beta-blockers for patients with heart failure. Less expected has been the convergence between achievement in prosperous and deprived communities, the shortfall in deprived communities being subsumed by much larger overall gains. 2 As a result, QOF has been seen as one way of reducing health inequalities, as the targets apply equally to the whole …