The economic implications of the Portsmouth protocol

Background:
The underpinning assumption of pay-for-performance (P4P) systems is that providers respond to financial incentives. However, in the UK, the impact of payment-by-results (PbR), a form of P4P, on care is unclear. The objective of this qualitative case study is to understand the local financial dynamics within a system that financially rewards clinical activities.

Methods:
Staff who acted as decision-makers in a hospital that implemented a quality improvement initiative—‘The Portsmouth Tonsillitis protocol’—were purposively sampled for semi-structured in-depth interviews in July 2014. The interview included questions about knowledge of the protocol, views on financial incentives and other motivations.

Findings:
Financial gains to the hospital motivated all the participants. Compared to clinicians, administrators were more concerned about the economic implications of their decisions on the hospital. The attitude of individual clinicians towards receiving monetary reward was unclear but they were unequivocal that professionalism, control over bed spaces and patient care were more important motivators of performance.

Conclusion:
Hospitals are not single entities with a unitary focus but consist of groups that sometimes have dissenting objectives. PbR may have created healthy competition between hospitals; such competition filtered down to clinical teams who vie for bed spaces and revenue with potentially unintended consequences on the wider productivity of the hospital.