Despite the apparent success of the QOF in improving some aspects of clinical care, it has been criticised as being an obstacle to patient-centred medicine [
28], for not sufficiently remunerating the extra effort required by practices working in deprived areas [
29] and for encouraging neglect of clinical areas for which there are no clinical indicators [
30]. The QOF's utility for encouraging effective health promotion counselling appears questionable and whether incentives payments are ever appropriate for this is open to debate. Health promotion payments were introduced into UK primary care in 1990 [
31]; initially health promotion activity undertaken in specially-organised clinics, rather than during routine consultations was incentivised but soon discontinued on cost grounds; evaluation provided no evidence that, if continued, this health promotion approach would have been effective [
32]. Subsequently, another primary care health promotion scheme involving target payments for recording cardiovascular risk factors and giving lifestyle advice to patients was introduced, but this too was quickly scrapped [
33,
34]. Like the QOF, this system rewarded GPs for counselling patients and also relied on the doctors themselves to record when they had done this. Evaluation suggested that doctors principally made administrative changes in their recording of patients' lifestyle data to enable incentives to be claimed, rather than substantially altering preventive activities [
34]. Similarly, in an experimental study monitoring the introduction of an outcome based health promotion payment, in which GPs were remunerated for recording three month's abstinence from smoking by patients also encouraged administrative changes made to facilitate payment claims rather than meaningful clinical interventions against smoking [
27].