The quality and outcomes framework: triumph of technical rationality, challenge for individual care?

The pace of organisational change within the National Health Service over the last two decades has been bewildering. Yet for all that, the rituals and routines of day-today general practice have seemed to endure without significant alteration. By contrast, the impact of the Quality and Outcomes Framework (QOF) has, arguably, exceeded that of any other policy development since the Family Doctors' Charter of 1966. This huge national experiment in performance related pay has understandably attracted much international attention and is likely to continue to do so. Since its introduction in 2004, the effects of the QOF on quality of care have been the subject of pained debate. Six years on, that debate is being informed by an accumulating body of research. As the political and economic environment in the UK heralds further organ-isational disruption, searching analysis of this evidence is timely. This themed issue of Quality in Primary Care provides just such a multifaceted and state-of-the-art analysis of the QOF. Lester and Campbell begin by examining the origins of the QOF framework dating back to precursors that attempted to promote evidence based primary care. Much of the development of performance indicators was undertaken in their own National Primary Care Research and Development Centre. The metamorphosis of what began as a scheme for quality and improvement into a regulated, contractual framework now requires burgeoning technical support for development and implementation of 'feasible, valid, reliable and piloted ''Qofable'' clinical indicators'. 3 Peckham and Wallace show us the broad canvas of international evidence on pay-for-performance (P4P) schemes. It is striking to what extent the empirical research they amass already relates to the QOF. They find that, while P4P schemes can affect clinical behaviour and processes, the impact on more widely defined aspects of quality such as patient experience or outcomes is less clear. Many of the concerns arising from implementation of this new scheme were predictable on the basis of previous research on P4P. 4 Partly because of its scale and complexity, the impact of the QOF will always be hard to quantify. Thus far, there is weak evidence for what in North America is sometimes called the 'street lamp effect': activities outside the glare of financial scrutiny being neglected. Steel and Willems, in their review of research on the QOF, find that care for patients with conditions included in the QOF broadly increased in line with preceding secular trends, while care of …