The Quality and Outcomes Framework as a Biomedical Technology: Consequences for UK General Practice

Abstract

In April 2014 the Quality and Outcomes Framework (QOF), the largest pay-for-performance scheme in primary care in the world, completed 10 years of existence. During this period, medical anthropologists have given little attention to QOF as a biomedical technological innovation for improving quality in general practice. This thesis contributes to the study of biomedical technology in medical anthropology by exploring two questions. First, what QOF in itself entails, its main characteristics and boundaries? Second, what are its consequences for general practice and for professional staff? An ethnographic study was set up to explore the QOF 2013/14 contract year in two general practices in the UK, coupled with participant-observation in a GP training programme. The main findings can be summarised as follows: (1) based on Foucault’s concept of governmentality, QOF as a biomedical technology represents a biopower dispositif for controlling individual (anatomopolitics) and population (biopolitics) by instilling a self-monitoring professional working environment for securing compliance; (2) the QOF clinical fragmentary model based on monetary incentives has literally commodified health professional-patient relationships through an exchange of token-information predicated on patients’ bodily parts. In this quality scheme, commercial ethics tend to predominate over professionals’ ethics; (3) the QOF scheme has produced a series of behaviour ranging from organising the practice team in accordance to QOF’s rules (the ‘QOF game’) to ‘gamesmanship’ with regards to them. The latter is more common as the practice reaches the end of financial year. These behaviours have implications for quality data production, affecting research on QOF, since most of it depends on secondary data sources; (4) in following the QOF depression indicators as a ‘mediating category’ since their inception in 2006/07, the question of ‘quality’ indicator construction and data production is further highlighted. QOF as a biomanagerial technology exemplifies an important cultural change in the UK general practice since compliance with externally dictated policy and its associated technologies changes principles and behaviour, with little scope for a holistic practice.