Identifying unintended consequences of quality indicators: A qualitative study

Helen Lester, Kerin Hannon, Stephen Campbell

Research output: Contribution to journalArticlepeer-review

58 Citations (Scopus)


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.
Original languageEnglish
Pages (from-to)1057-1061
Number of pages5
JournalBMJ Quality and Safety
Issue number12
Publication statusPublished - 2011
Externally publishedYes


Dive into the research topics of 'Identifying unintended consequences of quality indicators: A qualitative study'. Together they form a unique fingerprint.

Cite this