BMJ Qual Saf 20:1057-1061 doi:10.1136/bmjqs.2010.048371
  • Original research

Identifying unintended consequences of quality indicators: a qualitative study

  1. Stephen M Campbell
  1. Primary Care Group, University of Manchester, Manchester, UK
  1. Correspondence to Professor Helen E Lester, NIHR School for Primary Care Research, University of Manchester, 7th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK; helen.lester{at}
  • Accepted 1 June 2011
  • Published Online First 21 June 2011


Background For the first 5 years of the UK primary care pay for performance scheme, the Quality and Outcomes Framework (QOF), quality indicators were introduced without piloting. However, in 2009, potential new indicators were piloted in a nationally representative sample of practices. This paper describes an in-depth exploration of family physician, nurse and other primary-care practice staff views of the value of piloting with a particular focus on unintended consequences of 13 potential new QOF indicators.

Method Fifty-seven family-practice professionals were interviewed in 24 representative practices across England.

Results Almost all interviewees emphasised the value of piloting in terms of an opportunity to identify unintended consequences of potential QOF indicators in ‘real world’ settings with staff who deliver day-to-day care to patients. Four particular types of unintended consequences were identified: measure fixation, tunnel vision, misinterpretation and potential gaming. ‘Measure fixation,’ an inappropriate attention on isolated aspects of care, appeared to be the key unintended consequence. In particular, if the palliative care indicator had been introduced without piloting, this might have incentivised poorer care in a minority of practices with potential harm to vulnerable patients.

Conclusions It is important to identify concerns and experiences about unintended consequences of indicators at an early stage when there is time to remove or adapt problem indicators. Since the UK government currently spends over £1 billion each year on QOF, the £150 000 spent on each piloting cohort (0.0005% of the total QOF budget) appears to be good value for money.


  • Funding This study was supported by a grant from the Department of Health.

  • Competing interests SMC and HEL are contracted to the National Institute for Health and Clinical Excellence to provide advice on removal of indicators and pilot new indicators for the Quality and Outcomes Framework.

  • Ethics approval Ethics approval was provided by the North West Liverpool Central Committee 09/H1001/74.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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