QOF_Goodhart's Law

What a load of QOF!

“Giving doctors bribes to focus on a specific condition is morally wrong and ethically wrong”

-Katherine Murphy, Patients Association

The allocation of scarce resources – it’s what economics is all about. However, when those scarce resources involve life & death decisions (literally!), their distribution becomes far more controversial from a moral standpoint.

After all, how do you put a price on a life? Is this a scenario where research is not such a good thing – after all, the QOF is all about hitting pre-agreed researched targets….


What is the Quality Outcomes Framework ‘QOF’?

The quality and outcomes framework (QOF) is part of the General Medical Services (GMS) contract for general practices and was introduced on 1 April 2004.

The QOF rewards practices for the provision of ‘quality care’ and helps to fund further improvements in the delivery of clinical care.

Source: NHS Employers website

The UK’s health budget is forecast to grow at the fastest rate of any of the sectors (+4% in 2017) to £145bn – this will represent almost 19% of government spending, making it the 2nd most ‘expensive’ sector after pensions. [Source: UK public spending]

So, with an ageing population and more pressure upon resources, it is clear that something has to be done…but what?


“One of the long-term concerns about the QOF was that it would lead to the neglect of conditions which aren’t incentivised”

Tim Doran, professor of health policy at the University of York

Aside from the moral question of resource allocation, the key question remains – is QOF effective and value for money?

About QOF 

  • The Quality Outcomes Framework ‘QOF‘  was introduced by the Labour government in 2004
  • It is a national scheme, costing around £1bn pa to run
  • Scotland voted to abolish QOF in 2016: “‘Today’s announcement of the removal of all QOF points from the next GP contract marks a significant shift towards placing more trust in the clinical judgment and professionalism of GPs,” – Shona Robison, Scottish Health Secretary
  • Around 1/4 of a GP’s income is dictated by targets laid down by the QOF, with their pay linked to a plethora of targets, such as taking a patient’s blood pressure, or putting them on statins
  • The QOF targets common diseases such as heart disease, diabetes
  • BUT
  • There are no bonuses to prevention of other serious complaints, such as hip fractures & cancer

A Lancet study into the effectiveness of QOF

  • The Lancet undertook a study comparing underlying health trends between the UK and 26 other countries over the past 7 years (since QOF was operational in the UK)
  • There was a 0.004% decline in mortality rates (4 deaths per 100.000) for targeted conditions and a 0.012% increase for non-targeted
  • Neither was deemed to be statistically significant 
  • Bluntly put – bribes to GPs failed to improve patient care!


Conclusion: Truth be told, this isn’t anything to do with the failure of research – something plainly needs to be done to control health spending – it is about the failure to implement research.

What it does do though, is bring to mind Goodhart’s Law, named after the economist Charles Goodhart, which can be paraphrased as follows:

“When a measure becomes a target, it ceases to be a good measure.”