PURPOSEThe consultation is fundamental to the delivery of primary care, but different ways of organizing consultations may lead to different patient experiences in terms of access, continuity, technical quality of care, and communication. Patients' priorities for these different issues need to be understood, but the optimal methods for assessing priorities are unclear. This study used a discrete choice experiment to assess patients' priorities. METHODSWe surveyed patients from 6 family practices in England. The patients chose between primary care consultations differing in attributes such as ease of access (wait for an appointment), choice (fl exibility of appointment times), continuity (physician's knowledge of the patient), technical quality (thoroughness of physical examination), and multiple aspects of patient-centered care (interest in patient's ideas, inquiry about patient's social and emotional well-being, and involvement of patient in decision making). We used probit models to assess the relative priority patients placed on different attributes and to estimate how much they were willing to pay for them. RESULTSAnalyses were based on responses from 1,193 patients (a 53% response rate). Overall, patients were willing to pay the most for a thorough physical examination ($40.87). The next most valued attributes of care were seeing a physician who knew them well ($12.18), seeing a physician with a friendly manner ($8.50), having a reduction in waiting time of 1 day ($7.22), and having fl exibility of appointment times ($6.71). Patients placed similar value on the different aspects of patient-centered care ($12.06-$14.82). Responses were infl uenced by the scenario in which the decision was made (minor physical problem vs urgent physical problem vs ambiguous physical or psychological problem) and by patients' demographic characteristics.CONCLUSIONS Although patient-centered care is important to patients, they may place higher priority on the technical quality of care and continuity of care. Discrete choice experiments may be a useful method for assessing patients' priorities in health care.

Although patients may themselves make limited use of choices, the existence of choice may, in theory, stimulate providers to improve quality of care. Patients do, however, want to be more involved in individual decisions about their own treatment, and generally participate much less in these decisions than they would wish.

PURPOSEWe conducted an in-depth exploration of family physicians' and nurses' beliefs and concerns about changes to the family health care service as a result of the new pay-for-performance scheme in the United Kingdom (Quality and Outcomes Framework [QOF]). RESULTS Participants believed the fi nancial incentives had been suffi cient to change behavior and to achieve targets. The fi ndings suggest that it is not necessary to align targets to professional priorities and values to obtain behavior change, although doing so enhances enthusiasm and understanding. Participants agreed that the aims of the pay-for-performance scheme had been met in terms of improvements in disease-specifi c processes of patient care and physician income, as well as improved data capture. It also led to unintended effects, such as the emergence of a dual QOF-patient agenda within consultations, potential deskilling of doctors as a result of the enhanced role for nurses in managing long-term conditions, a decline in personal/relational continuity of care between doctors and patients, resentment by team members not benefi ting fi nancially from payments, and concerns about an ongoing culture of performance monitoring in the United Kingdom. METHODS CONCLUSIONSThe QOF scheme may have achieved its declared objectives of improving disease-specifi c processes of patient care through the achievement of clinical and organizational targets and increased physician income, but our fi ndings suggest that it has changed the dynamic between doctors and nurses and the nature of the practitioner-patient consultation.

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.

PURPOSEWe undertook an in-depth exploration of the unintended consequences of pay-for-performance programs In England and California. METHODSWe interviewed primary care physicians in California (20) and England (20) and compared unintended consequences in each setting. Interview recordings were transcribed verbatim and subjected to thematic analysis. RESULTSUnintended consequences reported by physicians varied according to the incentive program. English physicians were much more likely to report that the program changed the nature of the offi ce visit. This change was linked to a larger number of performance measures and heavy reliance on electronic medical records, with computer prompts to facilitate the delivery of performance measures. Californian physicians were more likely to express resentment about pay for performance and appeared less motivated to act on fi nancial incentives, even in the program with the highest rewards. The inability of Californian physicians to exclude individual patients from performance calculations caused frustration, and some physicians reported such undesirable behaviors as forced disenrollment of noncompliant patients. English physicians are assessed using data extracted from their own medical records, whereas in California assessment mostly relies on data collected by multiple third parties that may have different quality targets. Assessing performance based on these data contributes to feelings of resentment, lack of understanding, and lack of ownership reported by Californian physicians.CONCLUSIONS Our study fi ndings suggest that unintended consequences of incentive programs relate to the way in which these programs are designed and implemented. Although unintended, these consequences are not necessarily unpredictable. When designing incentive schemes, more attention needs to be paid to factors likely to produce unintended consequences. Ann Fam Med 2009;7:121-127. DOI: 10.1370/afm.946. INTRODUCTIONT o improve health care quality, payers are increasingly using fi nancial incentives to reward physicians and medical groups that meet specifi c performance targets. There has been a rapid recent growth in the number of these pay-for-performance programs, which provide fi nancial incentives for quality improvement, in primary health care. 122 PAY F O R P ER F O R M A NC Emultispecialty medical groups and independent practice associations, or IPAs,5,6 which contract with health plans on their behalf), and incentive payments are made to these larger organizations as opposed to individual physicians or practices. In England, payments are made directly to practices, which are mostly groups of between 1 and 10 primary care physicians. These payments contribute as much as 30% of practice income. In most (but not all) of the California settings, the amount received by physicians is much lower.Although pay-for-performance programs may deliver on their stated goals, 7,8 they could have unintended effects on other aspects of care or on physician motivation. These effects include...

HeadlineEvaluating service innovations in health care and public health requires flexibility, collaboration and pragmatism; this collection identifies robust, innovative and mixed methods to inform such evaluations.

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Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules. Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews. Results: Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines. Conclusions: While the creation of a ''safety culture'' requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.