title: Implementation of pay for performance in primary care: a qualitative study 8 years after introduction.
abstract: BACKGROUND
  Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF).
  
  
  OBJECTIVE
  To obtain a longer term perspective on the implementation of the QOF.
  
  
  METHODS
  Qualitative study with 47 health professionals in 23 practices across England. Method Semi-structured interviews.
  
  
  RESULTS
  Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients' best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences.
  
  
  CONCLUSIONS
  Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care.
authors.affiliation: School of Health and Population Sciences, University of Birmingham, Birmingham.
authors.forename: Helen
authors.initials: H
authors.lastname: Lester
authors.forename: Tatum
authors.initials: T
authors.lastname: Matharu
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Mohammed
authors.forename: David
authors.initials: D
authors.lastname: Lester
authors.forename: Rachel
authors.initials: R
authors.lastname: Foskett-Tharby
mesh_terms: D001291:Attitude of Health Personnel; D019985:Benchmarking; D004739:England; D005260:Female; D058006:General Practice / Q000191:economics* / Q000458:organization & administration; D006801:Humans; D007588:Job Satisfaction; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction; D010816:Physician Incentive Plans / Q000191:economics / Q000458:organization & administration; D011320:Primary Health Care; D036301:Qualitative Research; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012052:Reimbursement, Incentive / Q000191:economics / Q000458:organization & administration