BMJ  2007;334 (30 June), doi:10.1136/bmj.39260.443970.3A

Editor's Choice

US editor's choice

The side effects of "P4P"

General practitioners in the United Kingdom are now three years into an ambitious quality improvement program called the quality and outcomes framework. Under this program, they receive financial rewards when they meet specified targets in delivering preventive care and treatments to their patients. Several studies have documented that the targeted services have increased in response to this "pay for performance" program. In a qualitative ethnographic study, Ruth McDonald and colleagues observed and questioned office staff in two general practices to better understand how the program has affected the processes of care and staff attitudes (doi: 10.1136/bmj.39238.890810.BE).

There was concern that the financial incentives might conflict with doctors' professional values; that they would bring about undesirable changes to practices; and that the resulting surveillance would have a negative impact. To examine these issues, the investigators interviewed most of the doctors, nurses, healthcare assistants, and front office staff in two English general practices, one large and one small. They also observed the practices and used their observations to guide their questions and compare interview responses with observed behaviors.

The study found that the two practices organized their responses to the new framework differently, but that doctors in both practices felt that they were being incentivized appropriately and that the new program led to improved quality of care. Some nurses did not like the increased focus on "checking boxes" to meet standards but they did like being put in charge of specific goals and targets. There were concerns about increased surveillance around the quality measures but in general internal motivation did not seem to be threatened.

In a related editorial, Canadians Arlene Bierman and Jocalyn Clark raise concerns that a single-minded focus on specific quality measures could have an adverse effect on equity (doi: 10.1136/bmj.39251.660127.AD). Because quality improvement programs can have different effectiveness in different groups, they can widen existing inequities unless carefully monitored. If P4P programs work less well in disadvantaged populations, for example, then the providers in those settings will essentially be penalized for working there. As the authors state, equity should be "an integral component of performance measurement."

Other particularly interesting and relevant articles this week include an update on the quest for an AIDS vaccine by Alison Tonks (p1346), a useful clinical review by the Breen family and others on driving and dementia (doi: 10.1136/bmj.39233.585208.55), and a short but instructive review of lactose intolerance by Shinjini Bhatnagar and Rakesh Aggarwal (doi: 10.1136/bmj.39252.524375.80).

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Relevant Articles

Lactose intolerance

Shinjini Bhatnagar and Rakesh Aggarwal
BMJ 2007 334: 1331-1332. [Extract] [Full Text] [PDF]

Performance measurement and equity

Arlene S Bierman and Jocalyn P Clark
BMJ 2007 334: 1333-1334. [Extract] [Full Text] [PDF]

Driving and dementia

David A Breen, David P Breen, John W Moore, Patricia A Breen, and Desmond O'Neill
BMJ 2007 334: 1365-1369. [Extract] [Full Text] [PDF]

Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study

Ruth McDonald, Stephen Harrison, Kath Checkland, Stephen M Campbell, and Martin Roland
BMJ 2007 334: 1357. [Abstract] [Full Text] [PDF]

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