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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 December 8; 335(7631): 1170.
PMCID: PMC2128639
Quality and Outcomes Framework

So what are we to do?

Trefor J Roscoe, general practitioner principal

I am astounded by Heath et al’s criticism of a process they admit has not yet shown its full benefits.1

They state that, “Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the quality and outcomes framework (QOF), it becomes so,” which suggests that we should all over-ride the evidence when it suits us.

The use of an eight year old reference about financial incentives not increasing immunisation rates in America is dubious. Does this evidence apply to 21st century British general practice? When UK general practitioners were incentivised in the 1992 contract, immunisation rates soared. I would rather ignore the reference and believe my clinical judgment and the past 15 years’ experience that payment for immunisation has given the UK one of the highest immunisation rates in the developed world.

They also say, “None of the framework measures estimate clinically important outcomes. What they assess is treatment processes that are supposed to lead to improved outcomes.” What is this referring to? Glycated haemoglobin correlates with complication rates in diabetes, so measuring it and getting it below the recommended value is clinically important. Reduced blood pressure levels are a measurable and important clinical outcome in various morbidities

The government chose to incentivise general practice in this way and to use the best evidence at the time to measure performance. Are the authors suggesting that evidence can be ignored, experts are wrong, and GPs should forgo one of the largest investments in general practice in the past 20 years? How will this benefit patients?

My clinical judgment tells me that what I am doing for my patients is improving their health so I will continue to do it, despite the current lack of evidence and Heath et al’s criticism of the process.


Competing interests: TJR is a GP with a high QOF score and patients who are benefiting.


1. Heath I, Hippisley-Cox J, Smeeth L. Measuring performance and missing the point? BMJ 2007;335:1075-6. (24 November.) [PMC free article] [PubMed]

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