Review of the Quality and Outcomes Framework in England

The Quality and Outcomes Framework (QOF), an incentive scheme in general practice, was introduced across the UK in 2004 to link payment to delivery of primary medical care. Drivers for its introduction included the recognition that there were variations between general practices in the quality of care and the need to increase investment to improve morale and recruitment in primary care. QOF, in the early years, led to a reduction in inequalities in delivery of those aspects of care that it incentivised. Currently, there is little variation in QOF achievement between practices – most derive maximum, or near maximum income from it.

The QOF had other effects, encouraging nurse-led multidisciplinary management of chronic disease to deliver incentivised services, and better practice computerisation, so that delivery could be recorded. However, the extent to which high QOF achievement means a higher quality service in general practice is not clear. Quality in primary care is difficult to define, but it certainly encompasses more than is measured by QOF. It is now explicit NHS policy to improve other aspects of primary care – in particular, to deliver better integrated, holistic and patient-centred care and more effective primary prevention in primary care. Whether QOF can deliver these policies has been questioned, as have its role in reducing inequalities and its ability to deliver better population health.

NHS England commissioned the Centre for Health Services Studies at the University of Kent, on behalf of the Policy Research Unit in Commissioning and the Healthcare System (PRUComm), to review the evidence of effectiveness of QOF in the context of a changing policy landscape. We examined the most recent evidence that QOF influences behaviour in general practice and health outcomes, taking a broad view of primary care quality. We also considered the evidence that QOF helps sustain changes in primary care and effects of withdrawing QOF indicators using recent patterns of QOF achievement and the published literature.

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