• Patient-centred care
• Safety culture
• Patient safety

In 2004, the UK introduced what was at the time the world's most ambitious pay-for-performance scheme, the Quality and Outcomes Framework or ‘QOF’. Twenty five per cent of general practitioners’ (GPs’) pay was tied to a complex set of 136 quality indicators, the majority of which were extracted electronically from GPs’ medical records.1 Typical indicators related to blood pressure control in hypertension or blood sugar control in patients with diabetes. However, GPs were given the opportunity to exclude patients from these quality calculations, and this was called exception reporting. If a GP ‘exception reported’ a patient (or an individual indicator), that patient (or indicator) was removed from the quality calculation with no financial penalty to the GP.

The rationale for exception reporting was that even the best evidence-based guidelines were never intended to apply to all patients who visit their doctor. For example, it would be inappropriate to expect a GP to try rigorously to control cholesterol in a patient with diabetes dying of lung cancer. Exception reporting was therefore designed to allow doctors’ discretion to use their clinical judgement in deciding what treatments were appropriate for individual patients. The system was also designed so that doctors were not penalised if patients were non-compliant with requests for routine follow-up appointments or if patients did not wish to receive a particular investigation or treatment. The full list of reasons that doctors could record when deciding to exception report a patient is shown in box 1.2