Background: Introduced in 2004 in the UK National Health Service and costing approximately £1billion per annum the Quality and Outcomes Framework (QOF) continues to provoke controversy as the largest natural experiment in pay for performance (P4P) of its kind. The accumulating evidence has important findings for practitioners and policy makers.\ud \ud Methods: Secondary analysis of research literature examining the impact of P4P and QOF on health and care.\ud \ud Results: Trend analysis suggests that improvements in indicators are only partly attributable to the QOF. More comprehensive data recording explains some of this increase. While the quality of chronic disease management in incentivised domains has improved, the opportunity costs of QOF are largely unevaluated. The evidence for a “street lamp” effect whereby the care of non-incentivised diseases is neglected is limited. Practices vary in rates of “exception-reporting” (exclusions from the denominator) but there is little evidence of ‘gaming’. QOF has effected role revision, promoting nurses with extended roles, salaried medical grades and healthcare assistants. Whereas the QOF may have added to nurses’ job satisfaction, doctors express reservations concerning fractured continuity of care, “tick box medicine” and the invasiveness of computerised protocols. Little is known of how users view P4P. Opportunity costs are largely unevaluated. \ud \ud Conclusions: The QOF has contributed to improvements in quality of primary care, but at considerable cost. P4P illustrates the law of unintended policy consequences, transforming general practice in unexpected ways. Further research is needed to track QOF’s impact on nursing roles, continuity of care and the patient experience
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