title: Impact of financial incentives on alcohol intervention delivery in primary care: a mixed-methods study.
abstract: Local and national financial incentives were introduced in England between 2008 and 2015 to encourage screening and brief alcohol intervention delivery in primary care. We used routine Read Code data and interviews with General Practitioners (GPs) to assess their impact.
  
  
  
  A sequential explanatory mixed-methods study was conducted in 16 general practices representing 106,700 patients and 99 GPs across two areas in Northern England. Data were extracted on screening and brief alcohol intervention delivery for 2010-11 and rates were calculated by practice incentive status. Semi-structured interviews with 14 GPs explored which factors influence intervention delivery and recording in routine consultations.
  
  
  
  Screening and brief alcohol intervention rates were higher in financially incentivised compared to non-incentivised practices. However absolute rates were low across all practices. Rates of short screening test administration ranged from 0.05% (95% CI: 0.03-0.08) in non-incentivised practices to 3.92% (95% CI: 3.70-4.14) in nationally incentivised practices. For the full AUDIT, rates were also highest in nationally incentivised practices (3.68%, 95% CI: 3.47-3.90) and lowest in non-incentivised practices (0.17%, 95% CI: 0.13-0.22). Delivery of alcohol interventions was highest in practices signed up to the national incentive scheme (9.23%, 95% CI: 8.91-9.57) and lowest in non-incentivised practices (4.73%, 95% CI: 4.50-4.96). GP Interviews highlighted a range of influences on alcohol intervention delivery and subsequent recording including: the hierarchy of different financial incentive schemes; mixed belief in the efficacy of alcohol interventions; the difficulty of codifying complex conditions; and GPs' beliefs about patient-centred practice.
  
  
  
  Financial incentives have had some success in encouraging screening and brief alcohol interventions in England, but levels of recorded activity remain low. To improve performance, future policies must prioritise alcohol prevention work within the quality and outcomes framework, and address the values, attitudes and beliefs that shape how GPs' provide care.
authors.affiliation: Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK. amy.odonnell@newcastle.ac.uk.
authors.forename: Amy
authors.initials: A
authors.lastname: O'Donnell
authors.affiliation: Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.|Department of Public Health and Wellbeing, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Haighton
authors.affiliation: Public Health England, Durham, UK.
authors.forename: David
authors.initials: D
authors.lastname: Chappel
authors.affiliation: Balance: The North East Alcohol Office, Durham, UK.
authors.forename: Colin
authors.initials: C
authors.lastname: Shevills
authors.affiliation: Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
authors.forename: Eileen
authors.initials: E
authors.lastname: Kaner
mesh_terms: D000437:Alcoholism / Q000175:diagnosis* / Q000517:prevention & control*; D001291:Attitude of Health Personnel; D004739:England; D005260:Female; D058006:General Practice / Q000191:economics* / Q000379:methods; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008403:Mass Screening / Q000191:economics / Q000706:statistics & numerical data; D010816:Physician Incentive Plans; D011320:Primary Health Care / Q000191:economics* / Q000379:methods
keywords: Alcohol drinking; Brief intervention; Mixed methods; Pay for performance; Primary health care; Screening