The Quality and Outcomes Framework: what have you done to yourselves?

Six years ago we were asked to write an accompanying editorial to a paper by Julia Hippisley-Cox and Mike Pringle from Nottingham University looking at the time requirements to implement the National Service Framework for cardiovascular disease.1^,2 At that time we raised concerns that the content of the consultations was at risk of being taken over by the agendas of well-meaning single disease interest groups, and that there were potential opportunity costs of this change. The 2004 Quality and Outcomes Framework (QOF) contract, based on 146 outcome indicators, links income to performance on a scale never before seen in the UK. To outsiders it seems that UK general practice has moved from having an internal framework of professionalism that supports it, to an external framework that holds it up and embraces a market model of healthcare with performance linked bonuses and its own acronym: P4P (pay for performance).

New Zealand looks set to follow the same path. On reading through the QOF indicator list, our concerns have deepened. The mix of indicators looks like a hotchpotch of intermediate clinical and practice based ‘outcomes’. The list has the hallmark of those who think in terms of contracts, numbers, and linear production- line performance targets. This all purports to be in the name of evidence-based care, but we have looked in vain for evidence underpinning this radical, risky, and very expensive policy.

The issue at the core of the relationship between QOFs and general practice is not the indicators chosen nor whether GPs should be paid what they are worth. The fundamental issue is a philosophical one that centres on the nature of professionalism, professional values, and the concept of good care.

State-driven clinical priorities are risking general practice's disciplinary identity. By allowing ourselves to be coerced into persuading …