Twenty years on, the QOF is a dead man walking. This isn’t a dramatic opinion. It’s a conclusion backed by the BMJ’s own systematic review, published in June 2025, which looked at 30 studies covering both the introduction and withdrawal of financial incentives under the UK’s flagship pay-for-performance programme. The bottom line? QOF doesn't work. At least, not in the way it was sold to policymakers or practices.
The results are quietly devastating. While QOF showed some short-term upticks in recorded quality metrics - most notably in process indicators that were underperforming before being incentivised - those gains plateaued by three years and then reversed once the money dried up. In fact, the drop in quality following withdrawal of incentives often exceeded the gains seen when they were first introduced.
Let’s be clear about what QOF actually measures. It’s not real-world patient care. It’s tick-box data capture. The BMJ review found that QOF improved the recording of care processes (like foot checks for diabetes), but improvements in actual outcomes like blood pressure control or HbA1c levels were inconsistent, marginal, or simply non-existent. For the indicators that matter, QOF delivered diminishing returns.
Even where care improved, it was fragile. Withdraw the money and the system forgets what it was doing. A diabetic foot check that only exists because a code is incentivised isn’t a marker of quality; it’s a marker of fragility. If it disappears the moment funding shifts, then it was never embedded in the first place.
What QOF utterly failed to do, is embed care into organisational behaviour. The BMJ data makes this brutally clear: performance dropped like a stone when incentives were withdrawn. There’s no resilience, no cultural integration. It’s a system of externally imposed compliance, not one of internalised clinical accountability.
It didn’t build systems. It built habits that only lasted as long as the money.
Worse, it likely undermined intrinsic motivation. Practices shifted attention to incentivised tasks, often at the expense of the nuanced, human, and clinically rich aspects of care. Continuity dropped. Patient experience suffered. And perhaps most damning of all, mortality didn’t shift. Two decades, billions of pounds, and no clear reduction in QOF-related mortality.
The answer isn’t another committee-driven framework. It’s infrastructure.
Across the country, parameter-based care is already being delivered silently, automatically and safely by BookYourGP. Instead of throwing cash at static indicators, we ingest data, monitor parameter thresholds, and trigger care in real-time. No dashboards to check. No games to play. No end-of-year panic to massage numbers. Just ongoing, auditable, resilient care.
If a patient with hypertension hasn’t had a BP check in 12 months, the system knows. If someone with diabetes has dropped out of care, it flags and recalls. Every action is linked to clinical logic, not a tick box. Every task is delegated transparently, coded properly, and uploaded with traceable clinical oversight. And when care is delivered, it sticks, because the infrastructure doesn’t switch off when funding models change.
This isn’t fantasy. It’s running, live, in dozens of surgeries. And unlike QOF, when a practice manager resigns or a GP goes on leave, the system keeps going. It’s built for operational continuity, not political theatre.
QOF was born in a different era: one where we thought behaviour could be bought, and care could be measured with crude proxies. It failed. Not because GPs didn’t try, but because the system never supported how care is delivered, only whether it was coded.
What we need now is parameter-level infrastructure that mirrors the realities of chronic disease management. Systems that embed care by default, without needing constant human input or funding carrots. Systems that respect the clinic, not the spreadsheet.
The age of performance targets is over.
The age of embedded, automated, accountable care has begun.