{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,4]],"date-time":"2026-10-04T10:31:18Z","timestamp":1791109878781,"version":"4.1.0"},"reference-count":22,"publisher":"BMJ","issue":"12","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["BMJ Qual Saf"],"accepted":{"date-parts":[[2011,6,1]]},"published-print":{"date-parts":[[2011,12]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>For the first 5\u2005years 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>Fifty-seven family-practice professionals were interviewed in 24 representative practices across England.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Almost all interviewees emphasised the value of piloting in terms of an opportunity to identify unintended consequences of potential QOF indicators in \u2018real world\u2019 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. \u2018Measure fixation,\u2019 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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 \u00a31 billion each year on QOF, the \u00a3150\u2008000 spent on each piloting cohort (0.0005% of the total QOF budget) appears to be good value for money.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjqs.2010.048371","type":"journal-article","created":{"date-parts":[[2011,6,21]],"date-time":"2011-06-21T20:31:15Z","timestamp":1308688275000},"page":"1057-1061","source":"Crossref","is-referenced-by-count":69,"title":["Identifying unintended consequences of quality indicators: a qualitative study"],"prefix":"10.1136","volume":"20","author":[{"given":"Helen E","family":"Lester","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kerin L","family":"Hannon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen M","family":"Campbell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2011,6,21]]},"reference":[{"key":"2025090412455701000_20.12.1057.1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa064964"},{"key":"2025090412455701000_20.12.1057.2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.294.14.1788"},{"key":"2025090412455701000_20.12.1057.3","first-page":"103","article-title":"Developing QOF indicators and the concept of Qofability","volume":"18","author":"Lester","year":"2010","journal-title":"Qual Prim Care"},{"key":"2025090412455701000_20.12.1057.4","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMhpr041294"},{"key":"2025090412455701000_20.12.1057.5","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa055505"},{"key":"2025090412455701000_20.12.1057.6","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(08)61123-X"},{"key":"2025090412455701000_20.12.1057.7","doi-asserted-by":"publisher","DOI":"10.1093\/pubmed\/fdp003"},{"key":"2025090412455701000_20.12.1057.8","doi-asserted-by":"publisher","DOI":"10.1191\/1463423606pc272oa"},{"key":"2025090412455701000_20.12.1057.9","unstructured":"Department of Health. 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London: Sage, 1997."},{"key":"2025090412455701000_20.12.1057.13","doi-asserted-by":"crossref","first-page":"1338","DOI":"10.1136\/bmj.c2710","article-title":"Should the Quality and Outcomes Framework be abolished?","volume":"340","author":"Gillam","year":"2010","journal-title":"BMJ"},{"key":"2025090412455701000_20.12.1057.14","doi-asserted-by":"crossref","first-page":"183","DOI":"10.3399\/bjgp11X567117","article-title":"Exception reporting in the in the Quality and Outcomes Framework: views of practice staff\u2014a qualitative study","volume":"61","author":"Campbell","year":"2011","journal-title":"Br J Gen Pract"},{"key":"2025090412455701000_20.12.1057.15","doi-asserted-by":"publisher","DOI":"10.1370\/afm.844"},{"key":"2025090412455701000_20.12.1057.16","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-9566.2008.01081.x"},{"key":"2025090412455701000_20.12.1057.17","doi-asserted-by":"publisher","DOI":"10.1370\/afm.946"},{"key":"2025090412455701000_20.12.1057.18","unstructured":"Merton RK . 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What Is Seen and What Is Not Seen. 1850. http:\/\/bastiat.org\/en\/twisatwins.html (accessed 20 Aug 2010)."},{"key":"2025090412455701000_20.12.1057.20","doi-asserted-by":"publisher","DOI":"10.1080\/01900699508525011"},{"key":"2025090412455701000_20.12.1057.21","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.b1242"},{"key":"2025090412455701000_20.12.1057.22","unstructured":"http:\/\/www.ic.nhs.uk\/statistics-and-data-collections\/supporting-information\/audits-and-performance\/the-quality-and-outcomes-framework\/qof-2008\/09\/data-tables\/prevalence-data-tables (accessed 23 Sep 2010)."}],"container-title":["BMJ Quality &amp; Safety"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjqs.2010.048371","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,4]],"date-time":"2025-09-04T19:46:05Z","timestamp":1757015165000},"score":1,"resource":{"primary":{"URL":"https:\/\/qualitysafety.bmj.com\/lookup\/doi\/10.1136\/bmjqs.2010.048371"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2011,6,21]]},"references-count":22,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2011,11,23]]},"published-print":{"date-parts":[[2011,12]]}},"alternative-id":["10.1136\/bmjqs.2010.048371"],"URL":"https:\/\/doi.org\/10.1136\/bmjqs.2010.048371","relation":{},"ISSN":["2044-5415","2044-5423"],"issn-type":[{"value":"2044-5415","type":"print"},{"value":"2044-5423","type":"electronic"}],"subject":[],"published":{"date-parts":[[2011,6,21]]}}}