Intended for healthcare professionals


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

BMJ 2007; 334 doi: (Published 28 June 2007) Cite this as: BMJ 2007;334:1357
  1. Ruth McDonald, research fellow,
  2. Stephen Harrison, professor,
  3. Kath Checkland, research fellow,
  4. Stephen M Campbell, research fellow,
  5. Martin Roland, director
  1. National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL
  1. Correspondence to: R McDonald ruth.mcdonald{at}
  • Accepted 2 May 2007


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.

Design Ethnographic case study.

Setting Two English general practices.

Participants 12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff.

Main outcome measure 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.


  • We thank the participants for their cooperation.

  • Contributors: RMcD and KC carried out the fieldwork. RMcD, SH, KC, and SMC designed the study, undertook data analysis, and wrote the paper. MR contributed to the analysis and writing the paper. RM was principal investigator and is the guarantor.

  • Funding: This work was done at the National Primary Care Research and Development Centre, which receives funding from the Department of Health. The views expressed are those of the authors and not necessarily those of the Department of Health.

  • Competing interests: MR was one of a small group of academic advisers to the BMA and NHS Confederation negotiating teams, which developed the original quality and outcomes framework in 2002.

  • Ethical approval: South Cheshire local research ethics committee.

  • Accepted 2 May 2007
View Full Text