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New contracts for GPs

What changes when doctors' financial incentives change?

Launched in April 2004, the new general practice General Medical Services (GMS) contract for general practitioners (GPs) in effect pays doctors for performance. Significantly increased resources are now available, but up to one third of a GP’s income is dependent on the quality of care they provide measured against 146 clinical and organisational indicators. GPs have responded to specific financial incentives in the past by improving their performance, but the new contract is unprecedented in scale, and the overall effect of such a radical change is uncertain.

Researchers will examine how GPs respond to the new contract and what it will mean for patients and all those working in surgeries. Only certain specific areas of health are covered by the performance indicators, for example, cardiovascular disease. The study will analyse whether care for these ‘incentivised’ conditions improves at the cost of the care for ‘non-incentivised’ conditions such as mental, child and sexual health. Moreover, most of the organisation and delivery of contract care is likely to fall on nurses and administrative staff who have little direct financial incentive to deliver contract standards. What will their reaction be in terms of motivation and behaviour?

What the research means for policy makers and the wider community

Research methods

This study will use focus groups of primary care professionals in different regions to examine how all those working in surgeries are responding to the new GP contract. Researchers will then carry out detailed case studies within two practices using documentary, observational and interview data to explore how the practice prioritises different kinds of work, how these priorities and implemented, and the impact on patient care.

Further Information: Project Poster

Below is a summary of this project’s provisional findings. It was originally presented as a dissemination poster, which is available here as a pdf document. All figures can be found at the bottom of this poster summary as thumbnails, which one should click to view full-size images. Alternatively, where figures are reffered to in the text, click the linked text for a full-size version.




The link between the quality of health care and incentive systems is much debated, and the 2004 General Medical Services Contract in the UK offers a key test of that connection. The contract linked 25% of practice income to performance on 147 publicly- reported indicators that made up the Quality and Outcomes Framework (QOF see Figure 1). Contrary to expectations, most GP practices achieved over 90% of their QOF targets (pushing costs over the level budgeted for by approximately £1.5 billion in 2005*), but what is unknown is how this effect was achieved. 

* As reported by the Technical Steering Committee in the British Medical Journal, March 2006


Against that unexpected outcome, we aimed to discover how the 2004 contract affected the day-to-day operation of GP practices in Scotland.

» Did the QOF lead to improved organisation of care, in the form of registration and recall systems and protocols?

» Did it change the division of labour within practices (to more specialized GPs, nurse-led care, a bigger role for practice managers)?

» What was the biggest motivation in adhering to the QOF (financial advantage, better treatment practice, fear of adverse media comment)?

What We Did

» We examined quantitative reported data on workload and activity to produce a before-and- after analysis of clinical quality and determine whether non-incentivised conditions (such as mental health) were being crowded out in favour of incentivised ones (such as cardiovascular disease).

» We studied attitudes and perceptions by a staged process of qualitative analysis in three Scottish health boards with GPs, practice nurses and practice managers (Figure 3), then conducting in-depth fieldwork in two different GP practices in Tayside (Figure 2) to explore changes taking place at the front line.

Provisional Findings

» When we put together data on behaviour with data on attitudes we found attitudes varied more than behaviour.

» The public reporting of QOF activity had the unintended effect of making GP practices benchmark their financial performance against their peers.

» Disease registers, recall systems and nurse-led, protocol- driven care were perceived to have led to higher quality care for incentivised conditions, but to have led to other conditions (like depression) being crowded out, and this is supported by our early quantitative evidence.



Click on the figures to enlarge

guthriefig1.jpg              guthriefig2.jpg              guthriefig3.jpg

Other Project Outputs and Related Webpages

Project page on the ESRC Society Today website

Project page on the Economic and Social Data Service website

Grant, S., Huby, G., Watkins, F., Checkland, K., McDonald, R., Davies, H., Guthrie, B. (2009) The impact of pay-for-performance on professional boundaries in UK general practice: an ethnographic study, Sociology of Health and Illness,  Vol 31 (2):229-245

Checkland, K.; Harrison, S.; McDonald, R.; Grant, S.; Campbell, S.; Guthrie, B. (2008) Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract (2008) Sociology of Health and Illness, 30, 5, 788-803.

Huby, G.; Guthrie, B.; Grant, S.; Watkins, F.; McDonald, R.; Checkland, K.; Davies, H. (2008) Whither British general practice after the 2004 GMS contract? Stories and realities of change in four UK general practices, Journal of Health Organisation and Management, 22, 1, 63-78.

Research Team

Bruce Guthrie

Bruce Guthrie

Bruce Guthrie is a Health Foundation/Chief Scientist Office Postdoctoral Research Fellow at the Department of Community Health Sciences, University of Dundee, and additionally works as a general practitioner in a health centre in West Lothian. His research interests are in the definition and measurement of quality of care, and the effects of changing organisation on clinical quality, patient experience of care, and professional work and identity.

Tel: 01382 420 020

Guro Huby

Guro Huby

Guro Huby is Senior Research Fellow in the Department of Community Health Sciences, General Practice and leads the Scottish School of Primary Care’s Research Based Development of Scottish Primary Care Initiative. Guro is a social anthropologist with research interests in theory and models of research-based change in the NHS, organisational culture and organisational change, user perspectives on care and user participation in service development and health care for older people


Huw Davies

Huw Davies

Huw Davies is Professor of Health Care Policy and Management at the University of St Andrews, and a former Harkness Fellow in Health Care Policy. He is Co-Director of both the Centre for Public Policy & Management, and the ESRC-funded Research Unit for Research Utilisation in the University of St Andrews. His research interests include public service delivery (especially health care) and the role of organisational culture in the delivery of high quality services.