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J Public Health (Oxf). 2014 Jun;36(2):251-8. doi: 10.1093/pubmed/fdt077. Epub 2013 Aug 8.

The use of financial incentives to help improve health outcomes: is the quality and outcomes framework fit for purpose? A systematic review.

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Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
Centre for Health Services Studies, University of Kent, George Allen Wing, Canterbury, Kent CT2 7NF, UK Policy Research Unit in Commissioning and the Healthcare System, University of Manchester and CHSS, UK.



The quality and outcomes framework (QOF) is one of the world's largest pay-for-performance schemes, rewarding general practitioners for the quality of care they provide. This review examines the evidence on the efficacy of the scheme for improving health outcomes, its impact on non-incentivized activities and the robustness of the clinical targets adopted in the scheme.


The review was conducted using six electronic databases, six sources of grey literature and bibliography searches from relevant publications. Studies were identified using a comprehensive search strategy based on MeSH terms and keyword searches. A total of 21,543 references were identified of which 32 met the eligibility criteria with 11 studies selected for the review.


Findings provide strong evidence that the QOF initially improved health outcomes for a limited number of conditions but subsequently fell to the pre-existing trend. There was limited impact on non-incentivized activities with adverse effects for some sub-population groups.


The QOF has limited impact on improving health outcomes due to its focus on process-based indicators and the indicators' ceiling thresholds. Further research is required to strengthen the quality of evidence available on the QOF's impact on population health to ensure that the incentive scheme is both clinically and cost-effective.


QOF; indicators; primary care

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