Pay for performance systems in general practice: experience in the United Kingdom.

P4P has raised the quality of primary care in the UK, but broader performance indicators are needed to accurately reflect the scope of general practice ay for performance, or " P4P " as it is often known, is now centre-stage in primary care in the United Kingdom. P4P promotes change in clinical behaviour by offering financial rewards in return for achieving certain predefined targets. Both sides of the P4P " equation " are currently the subject of much debate: how generous should the financial reward be (the first " P "); and which performance indicators (the second " P ") should be used as the basis for calculating eligibility for the reward? From the foundation of the UK National Health Service (NHS) in 1948, general practitioners derived their income largely from capitation. Income was related more to the quantity than the quality of care. In 1990, and against much resistance from within the profession, the first performance targets were introduced into primary care. There were just two: rates of cervical smears and childhood vaccines. All this changed in 2004, when GPs accepted a new contract that radically promoted the role of P4P. This new contract tied about 25% of GP income to the achievement of a panoply of performance indicators. Large financial rewards were within reach for GPs able to achieve targets set for 147 performance indicators (subsequently revised to 135 indicators in 2006 and further revised to 128 in 2008). Details of the original 147 performance indicators and the mechanism for tying them to financial rewards have been well documented. 1 The overall structure is known as the " Quality and Outcomes Framework " (QOF). In essence, the indicators are a mix of clinical indicators covering the management of 10 long-term conditions (eg, diabetes, coronary heart disease, hypothyroidism) and a series of indicators covering managerial, organisational, educational, prescribing and " patient experience " aspects (eg, undertaking an approved patient survey each year) of primary care. The clinical indicators are a mix of process indicators (such as creating a disease register or conducting a specific investigation), intermediate, or proxy, outcome measures (such as reduced cholesterol levels), and true outcome measures (such as improved epilepsy control). Achievement of an indicator is converted into " quality points " , which are weighted according to the perceived workload required to attain the target set for each indicator. Each quality point attracts a fee …