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Br J Gen Pract. 2009 May 1; 59(562): 376.
PMCID: PMC2673169


This essay raises a number of important questions for primary care, none of which have easy answers.1 Professor Richards is right to highlight the dangers of a continuum from probity to game playing and perhaps fraud, and to highlight the ‘within practice’ tensions that can be created when practitioners sit at different places on this spectrum. For the record, I agree with his approach and think the moment you start bending QOF rules and stray from an essentially purist view of blood pressure recording or exception reporting, you enter tiger country. However, I disagree with his assertion around gaming that ‘after all everyone is doing it.’ The evidence to date, though limited, suggests we are not.

We know from Tim Doran's work on exception reporting that in the second year of QOF,2 practices exception reported a median of 5.3% of patients (interquartile range = 4.0–6.9). There was variation in this generally low level of reporting depending on the type of indicator (higher in the more demanding intermediate outcome than process measures) which could be interpreted as gaming. However, it is far more likely to reflect legitimate clinical concerns. Analysis of Scottish data found that rates of exception reporting in 2005–2006 were higher for practices that had levels of achievement below the maximum thresholds in the previous year than for those that had levels above the maximum thresholds.3 Once again it is possible that some practices gamed exceptions to maximise their income. However, the lack of association between the rate of exception reporting and the size of financial incentive attached to each indicator suggests that extensive gaming of exception reporting is unlikely to have occurred. So, while I agree that there is a grey animal in the room, I suspect it's of mouse-like proportions.

There is, however, a caveat. My worries around QOF, motivations, money, and behaviour are far greater for the next generation of doctors than the current ones. Medical students, GPs in waiting, are becoming rapidly accustomed to media descriptions of our avarice and will be initiated, while in debt, into a culture where pay for performance makes up 20% of their income. Will it be harder to take a purist approach in those circumstances? One solution might be to decrease the financial importance of QOF in line with other international pay-for-performance systems.4 I wonder, then, if even the mouse would get out of bed?


1. Richards J. Is there an elephant in the room? Br J Gen Pract. 2009;59:376–377. [PMC free article] [PubMed]
2. Doran T, Fullwood C, Reeves D, et al. Exclusion of patients from pay-for-performance targets by English physicians. N Engl J Med. 2008;359:274–284. [PubMed]
3. Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: further evidence from the Quality and Outcomes Framework. University of York: Centre for Health Economics; 2008. CHE research paper 34.
4. Rosenthal M, Landon B, Howitt K, et al. Climbing up the pay for performance learning curve: where are the early adopters now? Health Affairs. 2007;26:1674–1682. [PubMed]

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners