Aim and research question
The aim of this thesis was to explore P4P as incentive system in health care, and I wanted more specifically to do a review of the current literature, and also explore GPs' experiences with P4P and QOF in UK. My main research questions have been: Does P4P/QOF give quality improvement and to what price? How does QOF influence quality? What are the positive and negative effects? Does QOF influence ethical reflections or mindset of good doctoring?
Price is used in this thesis in a broad sense, by including both the price to pay in an ethical way, in relation to the patient -doctor relationship, professional, working force, money a.o.
Material and method
I have done unstructured literature searches, and collected data on GPs’ experiences through interviews with five GPs in UK.
The literature suggests that the QOF system seems to improve quality measures in diagnoses with clear endpoints, like diabetes, hypertension and some others. One could question if the improvement lasts, and also if improvement in quality measures causes better outcomes and care for patients. In sum, although there exists a huge amount of data, the evidence on the efficiency of P4P is scare and inconclusive. There are negative effects that have to be studied more thoroughly. In the interviews, GPs experienced that QOF had lifted “every doctor to the same bar” and given them a longed systematic approach to managing certain diagnoses. The system of QOF seemed to have eliminated the worst practices, but at the same time it left little room and no incentives for the exploration of excellence. GPs reported side effects of QOF that need to be taken into account.
In order to improve quality, we have to include all the dimensions of the term; Safety, Effective, Patient centered, Efficient, Timely, Equitable . Incentive systems have no value in themselves; they are just one among many tools to influence what happens in clinical practice. Future attempts to measure quality in primary care should take the unique complexity of primary care into account. We then need to engage multiple perspectives and multiple levels.