DB’s Medical Rants

The Experience of Pay for Performance in English Family Practice: A Qualitative Study

PURPOSE We conducted an in-depth exploration of family physicians’ and nurses’ beliefs and concerns about changes to the family health care service as a result of the new pay-for-performance scheme in the United Kingdom (Quality and Outcomes Framework [QOF]).

METHODS Using a semistructured interview format, we interviewed 21 family doctors and 20 nurses in 22 nationally representative practices across England between February and August 2007.

RESULTS Participants believed the financial incentives had been sufficient to change behavior and to achieve targets. The findings suggest that it is not necessary to align targets to professional priorities and values to obtain behavior change, although doing so enhances enthusiasm and understanding. Participants agreed that the aims of the pay-for-performance scheme had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. It also led to unintended effects, such as the emergence of a dual QOF-patient agenda within consultations, potential deskilling of doctors as a result of the enhanced role for nurses in managing long-term conditions, a decline in personal/relational continuity of care between doctors and patients, resentment by team members not benefiting financially from payments, and concerns about an ongoing culture of performance monitoring in the United Kingdom.

CONCLUSIONS The QOF scheme may have achieved its declared objectives of improving disease-specific processes of patient care through the achievement of clinical and organizational targets and increased physician income, but our findings suggest that it has changed the dynamic between doctors and nurses and the nature of the practitioner-patient consultation.

Those who champion P4P make an unfortunate assumption.  They believe that you can push one button, and only impact the desired outcome.  They are obsessed with measurement, and believe that measurement will improve health care.  They are so dangerous.

I will state that those who champion P4P are mistaken in the most dangerous way.  Unless we carefully study the impact of incentives we could cause more harm than good.

Bob Wachter talked about this eloquently in March - The Great Quality Debate: Berwick’s Plea for Action vs. Evidence-Based Medicine. 

On the other hand, in our zeal to “do something,” vigorously promoting or mandating practices with weak evidence risks squandering scarce resources, diverts us from better strategies, and subjects the safety field to the whims of opinions and biases. Berwick worries that our EBM pushback gives intellectual ammo to the dark forces of status quo. This is a reasonable concern. But given the public interest in quality and patient safety, I worry more that the distance between “this seems like a good idea” to “let’s include it as part of a campaign” to “let’s make it a new Joint Commission standard” to “let’s make it a state law” is perilously short. Accordingly, we should require awfully strong evidence that we’re doing the correct thing as we traverse that path, particularly when practices are complex and expensive.

The Annals of Family Medicine article raises many legitimate questions about Great Britain’s P4P experiment.  We should learn from their experience.