reimbursement for information technology. (IT) systems ... crisis in recruitment and retention of GPs. By. 2001 ... improve physicians' job satisfaction, pay, and.
Lessons From Abroad By Tim Doran and Martin Roland 10.1377/hlthaff.2010.0069 HEALTH AFFAIRS 29, NO. 5 (2010): 1023–1029 ©2010 Project HOPE— The People-to-People Health Foundation, Inc.
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Lessons From Major Initiatives To Improve Primary Care In The United Kingdom Primary care in the United Kingdom faced a crisis in 2000. General practitioners (GPs) complained of low morale, long hours, and low pay. The quality of care delivered to patients, meanwhile, was highly variable. The U.K. government responded with a program of quality improvement initiatives, a substantial increase in funding, and an ambitious pay-for-performance scheme that introduced publicly reported quality-of-care targets. Following these reforms, GPs’ income and morale increased, the number of working hours declined, and the quality of care improved. The reforms, however, presented a serious challenge to medical professionalism, and the long-term effects on patient outcomes remain uncertain. ABSTRACT
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he National Health Service (NHS) in the United Kingdom maintains a strong primary care base built around the general practitioner (GP), comparable to family practitioners in the United States. They have five years of training after medical school graduation and usually work in groups of two to six, employing a small team of nursing, reception, and administrative staff. Most U.K. family practices are owned by general practitioners and derive most of their income from providing services for the NHS under a national contract that defines services and compensation. Doctors can also serve privately paying patients. Nearly everyone in the United Kingdom is registered with a GP. These physicians typically have a caseload, or panel, of 1,500–2,000 patients. They provide all primary care to patients, who can generally see specialists only following a GP’s referral. General practice in the United Kingdom reached its nadir in the 1950s, with low recruitment, poor quality, and conditions “bad enough to change a good doctor into a bad one within a very short time,” as a contemporary report in the journal Lancet put it.1 Subsequent governments have sought to improve the quality of care
Tim Doran (tim.doran@ manchester.ac.uk) is Harkness Fellow in Health Care Policy at the Harvard School of Public Health in Boston, Massachusetts. Martin Roland is a professor of health services research at the University of Cambridge in England.
through reforms including mandatory vocational training for general practice; incentives for physicians to work in groups; financial support for improving practice facilities; partial reimbursement for information technology (IT) systems; reimbursing the cost of employed staff; limited pay-for-performance (introduced in 1990); and progressive increases in GPs’ incomes to levels often comparable with those of specialists. Nonetheless, in the 1990s low morale and perceived poor working conditions triggered a new crisis in recruitment and retention of GPs. By 2001, more than 90 percent of general practitioners surveyed said that they were overworked, undervalued, and underresourced. Three-quarters supported overhauling the national contract that, for them, translated to long working hours for lower incomes than specialists received.2 Long-standing concerns about quality and equity of care came to a head, and physician leaders finally accepted that clinical quality was measurable—and often substandard.3 The government recognized these problems and decided to place primary care at the center of its plans to modernize health services. Reforms began in 1998 with a comprehensive proM AY 2 0 1 0
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Lessons From Abroad gram of quality improvement. Quality-oriented statutory bodies were created to provide clinical effectiveness guidance, such as the National Institute for Health and Clinical Excellence, or NICE, and to improve health care quality regulation.4,5 These initiatives were matched by quality improvement activities promoted by the Royal College of General Practitioners. In 2000, responding to public concerns about quality, the government announced an increase in NHS funding to raise health care spending from 6.7 percent of gross domestic product (GDP) to the European average of 8 percent. Looking back, it is clear that the necessary conditions existed for major reform: a workforce dissatisfied with the status quo, and a government committed to improving quality and willing to back reform with substantial resources. Experience with pay-for-performance in the United Kingdom suggested that it could effectively promote change.6 Thus, a unique opportunity existed to link practice income to the quality of care through a revised national contract for general practitioners.
Changes In 2004 The new contract negotiated in 2004 aimed to improve physicians’ job satisfaction, pay, and conditions; recruitment and retention of physicians; and quality of care. The U.K. Department of Health and the British Medical Association negotiated for more than two years, starting in 2001. The new contract was an agreement with the general practice, not the individual physician. Practices were made responsible for care only during “core hours,” from 8 a.m. to 6:30 p.m. GPs could opt out of providing “outof-hours” care by paying £6,000 (the equivalent of $9,600) per year, and most did so. Primary Care Trusts—statutory bodies responsible for providing or commissioning health care for geographically defined populations— assumed responsibility for after-hours patient care. Base payments to practices remained listbased capitation, weighted for population factors including age and degree of socioeconomic deprivation. Additional resources depended on practices’ performance on quality indicators specified in a Quality and Outcomes Framework (QOF).7 Practices already achieving the quality-indicator targets would take most of the additional payment as income; others might need additional investment in staff and other practice resources. The contract did not specify how practices should reach the quality targets or use resources. Quality measurement depended on automatic data extraction from electronic records. The con1024
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tract increased the degree to which it reimbursed costs for health IT from 50 percent to 100 percent, with the Department of Health investing £200 million ($320 million) in health IT over the first three years.8 The new contract cost £1.1 billion ($1.8 billion) in its first year in England alone and £1.9 billion ($3.0 billion) in its second, increasing the primary care budget by a third.8 The original Quality and Outcomes Framework included 146 indicators covering clinical care for ten chronic diseases, organization of care, patient experience, and some additional services.7 Of the seventy-six clinical indicators, sixty-six concerned processes—for example, measuring blood pressure—and ten concerned intermediate outcomes—for example, controlling blood pressure within specified limits. Practices earned up to 1,050 points based, for clinical indicators, on the proportion of eligible patients for whom each target was achieved. The minimum achievement threshold was 25 percent; the maximum threshold varied from 50 percent to 90 percent, depending on the indicator. Each point earned £76 ($122) in the first year and £125 ($200) thereafter, adjusted for disease prevalence and list size. The original payment formula was not adequately modeled, and practices with high disease prevalence received less remuneration per patient than practices with low prevalence, thereby redistributing resources away from the neediest areas.9 As a result, the formula was revised in 2009. Physicians can exclude, through what are known as exception reports, patients for whom they judge particular indicators inappropriate or for administrative reasons (for example, the patient only recently registered with the practice). Practices’ quality scores are made public. The British Medical Association and the Department of Health review the Quality and Outcomes Framework in annual negotiations, revising indicators and adjusting points allocations and payment thresholds. Since 2009, NICE has examined evidence for existing and proposed quality indicators to provide recommendations for framework changes, but the British Medical Association and Department of Health negotiators retain the final decision. For both sides in the negotiations, paying for quality carried certain advantages. The Department of Health could demonstrate a return on its investment in better quality of care, while the British Medical Association was confident that members could meet the targets and greatly increase their incomes. The framework nevertheless proved controversial. Many physicians deemed centrally determined quality targets demeaning or threatening,
upsetting the balance between their public health responsibilities and their patientcentered ethos.10 Although some GPs believed that the framework’s attention to quality improvement would spill over to activities for which there were no incentives, others predicted that those activities would be neglected. Public reporting of physician quality, meanwhile, raised fears of political interference and gaming.
General Practice After 2004 Pay And Conditions Between 2002–3 and 2005–6, the average income of a GP who was also a senior practice partner increased nearly 60 percent, or by about £41,600, or $66,600. In 2006–7 there was a slight reduction in income, when the quality-indicator targets changed and the points were limited to 1,000. By 2006–7, however, the average income of all nonsalaried GPs was £107,000 ($171,200). More than onefourth of that income stemmed from pay under the Quality and Outcomes Framework. Three percent of GPs earned more than £200,000 ($320,000).11 GPs’ incomes are now closer to those of hospital specialists, who earn NHS salaries of £74,500–£176,200 ($119,200–$281,900) but have greater potential earnings from attending private patients. Not all general practitioners hold partnerships (a share of the practice business). Practices can employ salaried GPs who do not receive Quality and Outcomes Framework payments despite contributing to achieving practice targets. These physicians can earn £53,200–£80,400 ($85,100–$128,600). Although the pay gap has closed between primary and “secondary” or specialist and hospital care, a two-tier system now separates salaried and nonsalaried GPs.12 GP numbers increased 15 percent, from 26,833 to 30,931, during the first three years of the new contract. This was twice the Department of Health target. The vacancy rate—measured by positions that practices want to fill but for which they cannot find candidates—fell from 3.1 percent to 0.8 percent.8 The additional GPs preferentially chose more affluent areas, however, and the distribution of these physicians between affluent and socioeconomically deprived areas became less equitable.13 Most new posts were salaried; few practice principals offered the more lucrative partnerships. Nurses increased in number from 13,563 to 14,616 (7.7 percent), continuing a trend from the 1990s. Nurses took on more routine care for chronic conditions and patient consultations; they undertook a third of all consultations by 2006, as GPs continued to delegate responsibility to them.8
The British Medical Association repeated its survey of GPs in 2007. Fewer respondents reported low morale than had done so several years earlier. However, more than half of respondents continued to report low morale—citing excessive stress, diminished quality of life, or desire to change careers.14 In other longitudinal surveys, GPs reported working four hours fewer per week and having greater satisfaction with working conditions, responsibility, and job variety under the new contract (see the online Appendix).15,16 Meanwhile, surveyed nurses were largely positive about their increased responsibilities,17 but some resented not sharing the financial rewards.18 Quality Of Care Performance on most indicators in the framework was high in the first year and generally improved during the next two years.19 Practices scored, on average, more than 95 percent of available points by 2006–7, the third year.20 This exceeded the predictions of the Department of Health, which had budgeted for 75 percent attainment nationwide. A practice could score all available points by meeting the maximum thresholds even without achieving the quality targets for every single patient. Proportions of patients for whom the clinical indicators were met were therefore lower than point scores, but they still exceeded 80 percent overall.20 In 2004–5, practices’ performance varied widely, but the worst performers improved at the fastest rate. Because these practices were concentrated in the poorest areas, inequalities in quality of care for common chronic conditions quickly narrowed.19 Progressive incentives rather than absolute targets may have helped, as even practices with low baseline scores had incentives to improve. Improvements were slower for some ethnic minority groups, however.21 There was little further improvement in the fourth year. This may reflect the possibility that practices had reached their quality ceilings or exhaustion on the part of physicians working to improve. But the maximum achievement thresholds may also have mattered. There was little evidence on what levels of performance were achievable, so thresholds were initially set arbitrarily. By 2007–8, average national achievement exceeded the maximum threshold for all but three clinical indicators,20 most often substantially. In 2009 NICE recommended increasing maximum levels, but those negotiating on behalf of the GPs rejected this approach. Thresholds were kept below most practices’ level of performance, removing the financial incentive for further quality improvement. Quality of care for some chronic conditions M AY 2 0 1 0
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Lessons From Abroad was improving rapidly before the Quality and Outcomes Framework took effect.22 This suggests that the multiple initiatives previously introduced by the government and professional bodies were taking effect (see the online Appendix).16 Financial incentives for quality were associated with slightly more rapid quality improvement for some incentivized activities in the early years, after which quality improvements reached a plateau.22 One risk was that practices and Primary Care Trusts would concentrate their efforts, training, and education on activities that had incentives and neglect those that did not. For the latter, quality of care is harder to measure, because the activities are not routinely monitored, and evidence is mixed. Quality for nonincentivized activities associated with two framework conditions—asthma and coronary heart disease— deteriorated between 2003 and 2005. However, quality for nonincentivized activities associated with another framework condition—diabetes— improved.22 Meanwhile, care for patients with osteoporosis—outside the framework—neither improved nor deteriorated.23 The framework has also affected specialist care, through increased identification of patients with particular conditions and referrals for investigation.24 Some specialists complain of insufficient resources to meet the increased demand and resent not benefiting from the incentive payments, as the GPs do. The evidence on longer-term impacts on secondary care and outcomes is equivocal. Practices scoring highly on coronary heart disease indicators have not achieved significantly lower hospital admission rates.25 However, those showing improved control for patients with epilepsy and diabetes have modestly reduced emergency admissions for complications of these conditions.26,27 Changes To Practice Organization And Behavior As intended, practices have become more systematic and active in identifying and reviewing patients with the conditions that were subject to the physician incentives, developing protocols, and renewing appointment systems.17 Computing systems now provide prompts during consultations if a target applies, so patients’ presenting problems compete with frameworkrelated computer alerts.17,18 This raises fears that quantifiable aspects of care incentivized under the framework will be prioritized over less quantifiable aspects of care.28 Organizational changes made by practices in response to the incentives have created divisions, with some partners taking on a more managerial role, and even “chasing” colleagues who are not perceived to be contributing sufficiently.29 The framework also brought the wider issue of 1026
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professionalism into the spotlight. Although pay-for-performance aims to align physicians’ self-interest and professional values with the interests of the patient,7 clinical priorities may be subsumed to financial ones, and physicians’ intrinsic moral motivation to help patients may erode.18 This is a complex area, because in addition to financial incentives, the framework provides clinical guidelines and, through public reporting, reputational and competitive incentives. In interviews, GPs profess more enthusiasm for targets that they believe uphold professional values. On the other hand, it is clear that they also aim to achieve targets that aren’t necessarily geared purely to those values.17 Moreover, to add to the complexity, performance data suggest that money isn’t the sole motivation for high performance, as most practices exceed the maximum payment thresholds (see Appendix Exhibit 1).16 This reality suggests that altruism, professionalism, and reputational competition are important motivators as well.30 Nevertheless, GPs report that financial incentives have changed the nature of consultations,31 and, therefore, doubts remain about the longerterm effects on internal motivation. For example, influenza immunization rates for asthmatics fell after the corresponding indicator was removed from the framework in 2006–7.16 For many physicians, professionalism means exercising professional judgment, including judging when not to apply clinical guidelines. Pressuring a patient in order to achieve a target could be interpreted as professional or unprofessional behavior, depending on one’s perspective. Some practices admit to less willingness to let patients decline treatment for which there are incentives under the framework.31 Physicians are allowed to exempt patients from incentivized care, but they must report on these exceptions. This provision is essential; without it, the incentives would directly threaten the notion of patient-centered care, and patient respect and choice in particular. There are nevertheless concerns that practices could abuse “exception reporting” by inappropriately excluding patients who would benefit from an indicator activity. Most practices appear to have used exceptions appropriately for most indicators (overall rates of exception reporting have been below 6 percent), but a minority have unusually high rates that are difficult to justify clinically.32 Most practices have found the framework targets readily achievable and so have no incentive to report large numbers of exceptions. More demanding targets would increase the perverse incentive to inappropriately exclude patients.
This raises the issue of “gaming” and outright fraud. Although all payment systems are at risk of fraud, perverse incentives are more explicit under pay-for-performance. In interviews, GPs will admit to checking off indicators without fully satisfying all requirements.17 Because the incentive to overreport achievement is greater for the worst-performing practices, apparent gains in quality and equity under the Quality and Outcomes Framework may be partly illusory. In fact, some suspicious patterns are identifiable in the data, such as in recorded blood pressure values.33 Some practices may have removed “difficult” patients from their registers.34 Incontrovertible evidence of fraud, however, requires direct reporting of fraudulent activity or detailed examination of clinical records, or both. Patient Experience Patients should be the ultimate beneficiaries of reforms. However, the initial incentives focused on clinical and organizational measures that patients may not value. The original Quality and Outcomes Framework dedicated 9.5 percent of its points to indicators of patient experience, but these incentives related to conducting patient surveys and reflecting on them, rather than actual scores directly denoting patient experience. Thus, the targets could be easily achieved without providing a good patient experience. Nevertheless, these indicators habituated GPs to conducting patient surveys and reflecting on the results, neither of which was routine before 2004. The surveys were initially conducted by GPs themselves, but in 2009 an annual national survey was introduced for a random sample of 5.5 million patients, sufficient to give reliable results for all practices, and the results are publicly reported.35 Survey results have helped address some unintended consequences of the framework. Initially practices had an incentive to provide appointments within forty-eight hours. Many practices adopted a system of so-called Advanced Access, which prioritized seeing people on the day they requested a visit. This created a situation where patients were unable to book appointments ahead of time.36 This was clearly an unintended consequence. Two questions from the current national patient survey are now linked to payments in the Quality and Outcomes Framework: the ability to get an appointment “fairly quickly” if needed, and the ability to book appointments in advance. In 2009, 81 percent and 72 percent of respondents, respectively, reported that they could do so.35 Some GPs, particularly in poorer areas, feared that low response rates and selective nonresponse might disadvantage them with respect to these indicators, but nonresponse bias has not
been a major problem, and scores appear to be reliable at the practice level.37 Other aspects of the national survey are revealing. Of the 2.2 million respondents, 62 percent preferred seeing a particular doctor, but only 57 percent of them reported that they could do so “always or almost always.”35 Continuity of care matters to many patients, who see their relationship as being with a particular physician, not a particular organization. The drive to increase access to urgent care through Advanced Access may have made it harder for patients to see their regular physician.36 Overall, however, 91 percent of patients reported satisfaction with their care.35
Conclusion General practice has been central to the U.K. health care system for many years. The country is regarded as a leader in providing a health service led by primary care. This results from progressive support by the payer—largely the government—and the introduction over decades of measures to improve the quality of primary care. These include three years of mandatory vocational training for general practices in the 1970s, capital support for practice premises, support for health IT, and—since 1990—progressive introduction of measures to improve quality, such as requiring physicians to undertake regular clinical audits and early steps toward pay-forperformance. In the late 1990s, the government introduced a raft of “clinical governance” measures to further stimulate quality improvement. These included national guidelines for managing major chronic diseases, mandatory clinical audits, financial incentives, public release of information on quality of care, and annual appraisals of physicians. The measures generated major improvements in quality of care, especially for targeted chronic conditions such as ischemic heart disease and diabetes. These improvements were reinforced in 2004 with the introduction of a major pay-forperformance scheme. The Quality and Outcomes Framework greatly increased the incomes of most primary care physicians and brought modest further improvements in quality for incentivized activities, reductions in some inequalities in care delivery, and increases in physicians’ job satisfaction and recruitment to general practice. Having begun the decade in near-crisis, primary care in the United Kingdom excelled in cross-national comparisons of IT, access, chronic care management, performance review, and patient satisfaction by 2009.38 Most U.K. general practices currently meet the criteria M AY 2 0 1 0
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Lessons From Abroad for a patient-centered medical home. The reforms strengthened some aspects such as use of electronic records and publicly reporting performance, but they arguably weakened others, such as personal continuity of care. Although pay-for-performance and other quality improvement schemes may have improved chronic disease management, introducing a large and complex incentive scheme may have had adverse consequences. Some of these were clear-cut; for example, the incentive to provide appointments within forty-eight hours clearly made it harder for patients to book ahead. That problem was recognized and addressed, but adapting the Quality and Outcomes Framework in response to emerging evidence has sometimes been slow. Flaws in the payment formula were corrected only after five years, and most maximum payment thresholds have not been adjusted from their initial arbitrary levels. Some adverse consequences may relate to physicians’ being more focused on meeting targets than on meeting their patients’ needs.What can be measured becomes valued, and hence what is valuable comes to be what can be measured. This risk is increased because electronic health record systems often prompt physicians for data collection during routine consultations. The incentives might also have detrimental effects on working relationships within practices in the long term. Although shared goals can encourage cooperation, this is undermined if corporately earned rewards are not shared equitably. The long-term consequences of the reforms on professionalism cannot yet be fully assessed, and some blame pay-for-performance for doctors’ losing core patient-centered values. However, many changes have occurred in health care over this period, including doctors’—and European regulators’—desire for reduced working hours. Primary care physicians also wish to be relieved of twenty-four-hour responsibility for their patients. In addition, people have changed the way they view experts of all kinds, including physicians. The general population has increasing access to information previously only available to experts, and physicians have to adapt to a changed place in society. The U.K. experience with primary care reform offers lessons for other countries. However, they At the time of this writing, Tim Doran was supported by a grant from the Commonwealth Fund as a Harkness Fellow in Health Care Policy and
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should be applied cautiously for several reasons. Among these are the relative strength of general practice within the NHS, the uniquely generous funding from the government in the 2000s, and the distinct structure of U.K. practices—in particular, the involvement of nurses in providing consultations. It is particularly important to note that the Quality and Outcomes Framework was not intended to control costs, but rather to pay GPs for quality at a time when remuneration was being increased. There was therefore no initial financial threat to the physicians from the reforms. Paying doctors more while reducing their hours does generally make them happier. However, attaching performance targets to payments can generate suspicion and resentment, undermining the mutual trust between payer and provider that is essential for any incentive scheme—and any health service—to operate effectively. Introducing elements of quality into physician remuneration is technically and politically challenging, and results may be more modest than expected. Other consequenses may be unintended. Important lessons from the successes and failures of the Quality and Outcomes Framework include the following. (1) Install the necessary infrastructure (for example, by subsidizing health IT systems). (2) Establish baseline performance and identify associated factors, and set targets and budgets accordingly. (3) Involve physicians and patient groups from an early stage. (4) Base indicators on important outcomes where possible, and on processes with strong evidence of improved outcomes where not possible. (5) Do pilot studies of indicators and model payment formulae before introducing them. (6) Regularly review all elements of the scheme and their impact on patient outcomes, including those unrelated to the incentives. (7) Monitor the effects on professional behavior and morale. Financially incentivized quality targets are now integral to general practice in the United Kingdom, but the experience with pay-forperformance emphasizes that there is no magic bullet for quality improvement and that initiatives that produce long-term change are usually multiple in number and multilayered, and must be sustained over time to make a real difference. ▪
Practice. Doran advised the National Institute for Health and Clinical Excellence during its review of the Quality and Outcomes Framework in
2009. Martin Roland was an independent academic adviser to the original Quality and Outcomes Framework negotiations in 2003.
NOTES 1 Collings J. General practice in England today: a reconnaissance. Lancet. 1950;i:555–85. 2 British Medical Association. National survey of GP opinion. London: BMA; 2001. 3 Seddon M, Marshall M, Campbell S, Roland M. Systematic review of studies of quality of clinical care in general practice in the U.K., Australia, and New Zealand. Qual Health Care. 2001;10:152–8. 4 Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Department of Health; 2000. 5 Department of Health. New GMS contract 2003: investing in general practice. London: NHS Confederation and British Medical Association; 2003. 6 Baker D, Middleton E. Cervical screening and health inequality in England in the 1990s. J Epidemiol Community Health. 2003;57:417–23. 7 Roland M. Linking physicians’ pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med. 2004;351:1448–54. 8 National Audit Office. NHS pay modernisation: new contracts for general practice services in England. London: Stationery Office; 2008. 9 Guthrie B, McLean G, Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. Br J Gen Pract. 2006;56:836–41. 10 Lipman T. So how was it for you? A year of the GMS contract. Br J Gen Pract. 2005;55(514):396. 11 Information Centre. GP earnings and expenses enquiry 2006/07 final report. Leeds: Information Centre; 2009. 12 Gillies J, Mercer S, Lyon A, Scott M, Watt G. Distilling the essence of general practice: a learning journey in progress. Br J Gen Pract. 2009;59: 356–63. 13 Goddard M, Gravelle H, Hole A, Marini G. Where did all the GPs go? Increasing supply and geographical equity in England and Scotland. J Health Serv Res Policy. 2010;15: 28–35. 14 British Medical Association. National survey of GP opinion. London: BMA; 2007. 15 Whalley D, Gravelle H, Sibbald B. Effect of the new contract on GPs’ working lives and perceptions of quality of care: a longitudinal survey. Br J Gen Pract. 2008;58:8–14. 16 The online Appendix can be accessed by clicking on the Appendix link in the box to the right of the article
online. 17 Maisey S, Steel N, Marsh R, Gillam S, Fleetcroft B, Howe A. Effects of payment for performance in primary care: qualitative interview study. J Health Serv Res Policy. 2008;13: 133–9. 18 McDonald R, Harrison S, Checkland K, Campbell S, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. BMJ. 2007;334:1357–62. 19 Doran T, Fullwood K, Kontopantelis E, Reeves D. The effect of financial incentives on inequalities in the delivery of primary care in England. Lancet 2008;372:728–36. 20 Information Centre. Quality and Outcomes Framework—Online GP practice results database [Internet]. Leeds: Information Centre; [cited 2010 Apr 7]. Available from: http:// www.qof.ic.nhs.uk/ 21 Gray J, Millett C, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnicity and quality of diabetes care in a health system with universal coverage: population-based cross sectional survey in primary care. J Gen Intern Med. 2007;22(9):1317–20. 22 Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay for performance on the quality of primary care in England. N Engl J Med. 2009;361:368–78. 23 Steel N, Maisey S, Clark A, Fleetcroft R, Howe A. Quality of clinical primary care and targeted incentive payments: an observational study. Br J Gen Pract. 2007;57:449–54. 24 Hobbs H, Stevens P, Klebe B, Irving J, Cooley R, O’Donoghue D, et al. Referral patterns to renal services: what has changed in the past 4 years? Nephrol Dial Transplant. 2009;24(11):3411–9. 25 Bottle A, Gnani S, Saxena S, Aylin P, Mainous A, Majeed A. Association between quality of primary care and hospitalization for coronary heart disease in England: a national crosssectional study. J Gen Intern Med. 2008;23:135–41. 26 Shohet C, Yelloly J, Bingham P, Lyratzopoulos G. The association between the quality of epilepsy management in primary care, general practice population deprivation status, and epilepsy-related emergency admissions. Seizure. 2007;16: 351–5. 27 Doran T, Dusheiko M, Gravelle H, Roland M. Does higher quality of care in family practices reduce emergency hospital admissions? Evidence from diabetes management
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in the U.K.’s Quality and Outcomes Framework. Presented at: AcademyHealth Annual Research Meeting. Chicago (IL); 2009 Jun. Heath I, Hippisley-Cox J, Smeeth L. Measuring performance and missing the point? BMJ. 2007;335:1075–6. Grant S, Huby G, Watkins F, Checkland K, McDonald R, Davies H, et al. The impact of pay-forperformance on professional boundaries in U.K. general practice: an ethnographic study. Sociol Health Illn. 2009;31:229–45. Campbell S, McDonald R, Lester H. The experience of pay for performance in English family practice: a qualitative study. Ann Fam Med. 2008;6:228–34. McDonald R, Roland M. Pay for performance in primary care in England and California: comparison of unintended consequences. Ann Fam Med. 2009;7:121–7. Doran T, Fullwood C, Reeves D, Gravelle H, Roland M. Exclusion of patients from pay-for-performance targets by English physicians. N Engl J Med. 2008;359:274–84. Carey I, Nightingale C, DeWilde S, Harris T, Whincup P, Cook D. Blood pressure recording bias during a period when the Quality and Outcomes Framework was introduced. J Hum Hypertens. 2009;10:1038. Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: further evidence from the quality and outcomes framework. York: Centre for Health Economics; 2008. CHE Research Paper no. 34. The GP Patient Survey [home page on the Internet]. London: Department of Health; [cited 2010 Jan 2]. Available from: http://results .gp-patient.co.uk/report/main.aspx Salisbury C, Goodall S, Montgomery A, Pickin D, Edwards S, Sampson F, et al. Does advanced access improve access to primary health care? Questionnaire survey of patients. Br J Gen Pract. 2007;57:615–21. Roland M, Elliott M, Lyratzopoulos G, Barbiere J, Parker R, Smith P, et al. Reliability of patient responses in pay for performance schemes: analysis of national General Practice Patient Survey data in England. BMJ. 2009;339:b3851. Schoen C, Osborn R, Doty M, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Aff (Millwood). 2009;28(6): w1171–83.
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