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

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.