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BACKGROUND: The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff. METHODS: We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis. RESULTS: We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems. CONCLUSIONS: Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.

Original publication




Journal article


BMC Fam Pract

Publication Date





Meta-ethnography, Meta-synthesis, Pay for performance (P4P), Primary care, Qualitative research, Qualitative synthesis, Quality and outcomes framework (QOF), Quality initiatives, Efficiency, Organizational, General Practice, Health Personnel, Humans, Primary Health Care, Professionalism, Qualitative Research, Quality Improvement, Reimbursement, Incentive, United Kingdom