title: Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study.
abstract: OBJECTIVE
  To explore the impact of financial incentives for quality of care on practice organisation, clinical autonomy, and internal motivation of doctors and nurses working in primary care.
  
  
  METHODS
  Ethnographic case study.
  
  
  METHODS
  Two English general practices.
  
  
  METHODS
  12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff.
  
  
  METHODS
  Observation of practices over a five month period after the introduction of financial incentives for quality of care introduced in the 2004 general practitioner contract.
  
  
  RESULTS
  After the introduction of the quality and outcomes framework there was an increase in the use of templates to collect data on quality of care. New regimens of surveillance were adopted, with clinicians seen as "chasers" or the "chased," depending on their individual responsibility for delivering quality targets. Attitudes towards the contract were largely positive, although discontent was higher in the practice with a more intensive surveillance regimen. Nurses expressed more concern than doctors about changes to their clinical practice but also appreciated being given responsibility for delivering on targets in particular disease areas. Most doctors did not question the quality targets that existed at the time or the implications of the targets for their own clinical autonomy.
  
  
  CONCLUSIONS
  Implementation of financial incentives for quality of care did not seem to have damaged the internal motivation of the general practitioners studied, although more concern was expressed by nurses.
authors.affiliation: National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL. ruth.mcdonald@manchester.ac.uk
authors.forename: Ruth
authors.initials: R
authors.lastname: McDonald
authors.forename: Stephen
authors.initials: S
authors.lastname: Harrison
authors.forename: Kath
authors.initials: K
authors.lastname: Checkland
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Campbell
authors.forename: Martin
authors.initials: M
authors.lastname: Roland
mesh_terms: D005194:Family Practice / Q000191:economics* / Q000458:organization & administration / Q000592:standards; D006282:Health Personnel / Q000592:standards*; D011364:Professional Practice / Q000592:standards; D011787:Quality of Health Care; D012052:Reimbursement, Incentive; D006113:United Kingdom