Abstract
The new general practice contract introduced in 2004, fundamentally changed the professional landscape for British GPs. It moved from a largely capitation based system of remuneration to a system that aimed to reward quality, where a significant proportion of income could be earned by achieving evidence-based quality targets. These targets were set out in the Quality and Outcomes Framework (QOF) and represented £1.6 billion in investment contributing to 20% of practice income. Never before has there been such a large-scale system of payment for performance (P4P). The aims of the new contract were to improve the quality and unequal distribution of care in general practice, to help the retention and recruitment of GPs, as well as reward practices for the delivery of existing high quality care.1 While there is some evidence that change has been in a positive direction towards achieving these aims concern has been expressed regarding the unintended opportunity costs of the new contract.2 The new contract has also generated areas of moral controversy that need to be acknowledged, debated, and addressed. I had worried that, by being paid to implement evidence-based guidelines, my work would become a restricted, target-driven exercise that shifted the balance of my consultations to a doctor and disease-centred agenda. I had been concerned that this created conflicts of interest and how that might undermine, not only trust by my patients in me as a doctor, but also the trustworthiness of the profession. I worried that in some domains I was taking money to engage in work that I felt had limited value for my patients, money that could possibly be spent in more useful areas. Was I colluding in a wholesale folly of medical practice and worse still, why wasn't I doing anything about it? Had my mouth been effectively ‘stuffed …
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