Background: Introduced in 2004 as part of a new contract for General Practitioners in the National Health Service, the Quality and Outcomes Framework (QOF) continues to provoke controversy. QOF is the largest natural experiment in pay for performance (P4P) of its kind. The QOF cost approximately £X million in 2009 constituting approximately 22% of general practices’ income. The evaluative evidence base (to which the authors have contributed) is accumulating. It contains important findings for practitioners and policy makers.\ud \ud Methods: Secondary analysis of research literature examining pay for performance in health care and the QOF specifically.\ud \ud Results: Trend data suggest that rising attainments of evidence-based quality indicators are, in part, 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 remarkably in the proportion of patients that are “exception-reported” (and thereby excluded from the denominator) but there is little evidence of substantial ‘gaming’ to inflate practice incomes.\ud \ud Interviewed-based studies confirm that the QOF is effecting the re-division of labour at the front line. The need to staff protocol-driven diseased based clinics has promoted the training and employment of primary care nurses with extended roles, the employment of a salaried medical sub-grade and expanded opportunities for healthcare assistants. Nurses mostly view the QOF as having added to their job satisfaction. Doctors express more reservations concerning fractured continuity of care, “tick box medicine” and the invasiveness of computerised protocols. The QOF remunerates practices in the light of measures of patient satisfaction but little is known of how users view P4P.\ud \ud Conclusions: The QOF has improved the quality of British primary care – but at considerable cost. P4P illustrates the law of unintended policy consequences and the QOF is transforming British general practice in unexpected ways. Further research will be needed to track QOF’s impact on nursing roles, continuity of care and the patient experience. In the meantime, there are good reasons for containing its expansion
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