The payment for performance model and its influence on British general practitioners' principles and practice

Abstract

This article explores some effects of the British payment for performance model on general practitioners’ principles and practice, which may contribute to issues related to financial incentive modalities and quality of primary healthcare services in low and middle-income countries. Aiming to investigate what general practitioners have to say about the effect of the British payment for performance on their professional ethos we carried out semi-structured interviews with 13 general practitioner educators and leaders working in academic medicine across the UK. The results show a shift towards a more biomedical practice model and fragmented care with nurse practitioners and other health care staff focused more on specific disease conditions. There has also been an increased medicalisation of the patient experience both through labelling and the tendency to prescribe medications rather than non-pharmacological interventions. Thus, the British payment for performance has gradually strengthened a scientific-bureaucratic model of medical practice which has had profound effects on the way family medicine is practiced in the UK.

Health Care Professionals’ Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis

“…Table 1 provides details related to the time period of program implementation since the inception of P4P in the early 2000s (early, evolving, and routinization), as well as the program design as described by the authors of each article. Nine articles were focused on studies based in the United Kingdom, 34,35,39,40,42,43,[45][46][47] 7 articles in the United States, 33,37,38,48,49,51,52 1 article each in Tanzania, 36 Malawi, 44 France, 50 and the Netherlands. 41 Twelve articles focused on physicians, nurses, and health care professionals, 5 articles focused on physicians, one of which also included practice executives, 2 articles focused on practice executives/leaders, and 1 article focused on nonphysician health care professionals.…”

“…34 Another GP noted, "We have become so measurement-oriented, it's becoming more difficult for the patient and the doctor to have a genuine personal relationship around the patient's own circumstances." 47 In addition to the loss of patient-centered care described in studies, some P4P program participants noted a consistent concern about the loss of patient autonomy and devaluing a patient's agenda. 34,36,37,[45][46][47][48][49][50] Health care professionals noted that patient concerns or preferences were often marginalized.…”

“…Concern was raised about the validity of performance measures and quality targets as a measurement of quality. [33][34][35]37,45,47,51,52 Respondents noted that what is being measured does not necessarily represent quality or might be inconsistent with physicians' definitions of quality. There was a suspicion of the ability of measures to reflect quality of care and a recognition of the need to define value.…”

Unfashionable tales: narratives about what is (still) great in NHS general practice

“…Of particular significance was the 2004 contract in which the Quality and Outcomes Framework (QOF) linked payment to targets in the management of certain chronic conditions rather than for provision of services to patients. Studies confirmed that GPs responded to achieve those targets, 8 though possibly with relative inattention to other aspects of medical care. [9][10][11] Regulation and monitoring of primary care have increased in the form of appraisal and revalidation for all GPs, CQC inspections, clinical activity audits, and patient satisfaction surveys.…”

Prevenção quaternária: as bases para sua operacionalização na relação médico-paciente

“…A prevenção quaternária implica no fortalecimento e na reconstrução da capacidade crítica e epistemológica dos médicos de família, capacidades essas em franco declínio decorrente das transformações recentes da medicina, cada vez mais padronizada em protocolos, que induzem uma estandardização e generalização das interpretações e dos tratamentos, 30,31 pressupondo uma homogeneidade cada vez maior dos doentes, cuja singularidade pessoal e existencial-social-psicológica demanda justamente uma direção oposta, a personalização das interpretações e do cuidado. Assim, a prevenção quaternária induz os profissionais a manterem uma proximidade longitudinal e centrarem o cuidado nas pessoas e em suas vivências, protegendo-as de desvios induzidos pelos automatismos da ânsia diagnóstica e terapêutica.…”