For over 10 years, the Quality and Outcomes Framework ( QOF) largely defined the approach to "Quality" in General Practice. It was introduced in the 2004 nGMS contract with the intention of providing improved, or consistently high, quality of care, whilst offering GP practices an opportunity to increase funding via an incentivised payment scheme.
Whilst the quality of care delivered in general practice has undoubtedly improved since the beginning of the century, it is contentious to what extent QOF contributed to this effect. There is some evidence to suggest that in the early years it accelerated the pre-existing trajectory of improvement being seen in managing those chronic diseases that were included, and achieved greater equality in the standard of care across practices but that over time, and for a variety of reasons, this small effect became further diluted and was perhaps even achieved with the unintended consequence of crowding out other chronic conditions not included  .
Beyond this, voices within the profession began to express concerns about the volume of bureaucracy associated with QOF, and the effect that it was having on the consultation model with patients. Many expressed concern that this was directly influencing the profession towards a disproportionate emphasis on a biomedical model of care, which was less consistent with the values of general practice, and less fulfilling as a doctor to provide.
Over this same period, there has been an expansion of interest and understanding in the approaches to quality improvement in healthcare, and Scotland has been at the forefront of this. More recently, feedback following the publication of Realistic Medicine  in Scotland has demonstrated that doctors want to provide a more personalised approach to care and to tackle unwarranted variation in care, harm and waste within our healthcare system.
The healthcare system is changing in response to the demands placed upon it. The National Clinical Strategy for Scotland signals the transformation required in Primary Care so that it may fulfil its potential at the heart of this system. With the formation of GP Clusters in localities there is a need, and opportunity, to reconsider how we approach quality.
In his recent article in the Journal of American Medical Association, Dr Don Berwick suggested that it was now time for "Era 3" medicine; guided by updated beliefs and free of both the professional protectionism of era 1, and management reductionism of era 2  . To do this, requires a rejection of the controlling power exerted by exponents of these past eras, whether they be formed from professional trust and prerogative, or scrutiny and incentive. Instead, these should be replaced by beliefs and behaviours defined by a moral approach to medicine that has better, more realistic and appropriate, high quality, high value care as its aim.
This philosophy provides the context for this national framework to support the work of GP Clusters throughout Scotland. It is a step change to the approach for continuously improving the quality of care offered to our citizens and to improving the health and wellbeing of the Scottish population. It outlines the contribution of NHS Health Boards and Health and Social Care Partnerships in supporting GP clusters to fulfil this role and to enable meaningful GP participation in local planning that underpins the purpose of health and social care integration.
Improving Together will complement the development of the Scottish national GP contract that sets out the role of GPs and their important contribution as clinical leaders and expert medical generalists working in a community setting. This framework will be reviewed by the Scottish Government and the Scottish General Practitioners Committee of the BMA on a periodic basis, attentive to feedback from those involved in delivering its intent. As such, it is a framework that will develop to its full potential over time, as elements of the transformation of primary care in Scotland create the capacity to do so.
I am grateful and pay tribute to the commitment and dedication of the broad group of colleagues who have collaborated meaningfully to this framework and for their individual and collective support during its development.
Dr Gregor Smith
Deputy Chief Medical Officer for Scotland
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