`Just another incentive scheme’: a qualitative interview study of a local pay-for-performance scheme for primary care

Abstract

BackgroundA range of policy initiatives have addressed inequalities in healthcare and health outcomes. Local pay-for-performance schemes for primary care have been advocated as means of enhancing clinical ownership of the quality agenda and better targeting local need compared with national schemes such as the UK Quality and Outcomes Framework (QOF). We investigated whether professionals’ experience of a local scheme in one English National Health Service (NHS) former primary care trust (PCT) differed from that of the national QOF in relation to the goal of reducing inequalities.MethodsWe conducted retrospective semi-structured interviews with primary care professionals implementing the scheme and those involved in its development. We purposively sampled practices with varying levels of population socio-economic deprivation and achievement. Interviews explored perceptions of the scheme and indicators, likely mechanisms of influence on practice, perceived benefits and harms, and how future schemes could be improved. We used a framework approach to analysis.ResultsThirty-eight professionals from 16 general practices and six professionals involved in developing local indicators participated. Our findings cover four themes: ownership, credibility of the indicators, influences on behaviour, and exacerbated tensions. We found little evidence that the scheme engendered any distinctive sense of ownership or experiences different from the national scheme. Although the indicators and their evidence base were seldom actively questioned, doubts were expressed about their focus on health promotion given that eventual benefits relied upon patient action and availability of local resources. Whilst practices serving more affluent populations reported status and patient benefit as motivators for participating in the scheme, those serving more deprived populations highlighted financial reward. The scheme exacerbated tensions between patient and professional consultation agendas, general practitioners benefitting directly from incentives and nurses who did much of the work, and practices serving more and less affluent populations which faced different challenges in achieving targets.ConclusionsThe contentious nature of pay-for-performance was not necessarily reduced by local adaptation. Those developing future schemes should consider differential rewards and supportive resources for practices serving more deprived populations, and employing a wider range of levers to promote professional understanding and ownership of indicators.

Health Care Professionals’ Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis

“…Table 1 provides details related to the time period of program implementation since the inception of P4P in the early 2000s (early, evolving, and routinization), as well as the program design as described by the authors of each article. Nine articles were focused on studies based in the United Kingdom, 34,35,39,40,42,43,[45][46][47] 7 articles in the United States, 33,37,38,48,49,51,52 1 article each in Tanzania, 36 Malawi, 44 France, 50 and the Netherlands. 41 Twelve articles focused on physicians, nurses, and health care professionals, 5 articles focused on physicians, one of which also included practice executives, 2 articles focused on practice executives/leaders, and 1 article focused on nonphysician health care professionals.…”

“…55 Study participants noted that physicians and nurses were motivated to provide good quality care and that the P4P programs legitimized their intrinsic motivation to improve outcomes for their patients. 33,34,36,37,40,44,[50][51][52] "Personally, the incentives are just an addition, but my spirit is to help people. Nursing is a calling.…”

“…45 There was, however, significant concern noted about physicians' autonomy to make clinical decisions and their control, or lack thereof, of patients' decisions about their care that might negatively influence performance measurement, such as refusing a recommended screening colonoscopy. 33,36,40,43,51 Some physicians identified a need to regain control by modifying clinical targets based on individual patients, enabling the gray area of care delivery that is often enabled by physician clinical autonomy. "The more templates that get introduced, it takes away the clinician's freedom and that sort of rapport that you can build with a patient is much more difficult when you have to go through set questions," said one GP.…”

“…I don't know how others feel but I wouldn't like to come in last in our locality," said one practice manager. 40 One study participant noted the importance of success regardless of the program goals to ensure income, potentially impacting intrinsic motivation, but for others, money was seen as an "in addition to" motivator along with recognition and respect. Physicians and other health care professionals reported improved morale from financial incentives.…”

“…33,51 Unintended Consequences: Box-Checking, Measure Fixation, and the Potential for Gaming One consistent theme was that P4P led to box-checking and a fixation on measures that created tension in practice. 36,40,42,43,45,47 "So I think if this is going to become a tick-the-box exercise it might be that the question will be pushed at an inappropriate time, the wrong moment for the sake of some points," said one GP. 42 Another respondent noted, "the boxes were checked."…”