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Table 3 Application of the Synthesis to the Values and Implication for Professionalism

From: A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK

Main Themes

Application of the findings to the Values

Implications for aspects of professionalism [22]

(a) Loss of autonomy

Activated values

When values are stimulated, they become infused with feeling.

Therefore, GPs for whom independence is an important value may experience provocation if their independence (self-direction) seemed to be threatened, discouraged when they are helpless to keep their professional autonomy (power), and would be happy when they can enjoy their freedom as self-regulated practitioners (security).

Doctor as manager and leader

Loss of autonomy impacts clinical engagement and leadership which is pivotal to the success of health systems. Doctors make decisions that determine where resources flow. Yet there is a conflict experienced between doctors as employees of huge complex systems and the autonomy of individual doctors. Autonomy is crucial for the delivery of care, but modern autonomy is more complex and nuanced and needs greater judgement [22].

Control and ownership

Professionals appeared preoccupied by their lack of control in achieving indicator targets (achievement), especially if dependent upon patient cooperation, quality of care (security), and implementation of outsider perceived changes (power) [23, 24].

Doctor as team worker

Relinquishing control is important to allow an important component of teamwork as professional satisfaction, engagement, and effective teamwork improves patient outcomes and satisfaction, as well as organisational performance and productivity. Teamwork has become more important because of the growing complexity of patients’ problems and health systems, and the increasing range of possible interventions [22].

(b) Incentivised conformity

Motivating actions

Those GPs for whom social order, justice, and medical superiority (power, achievement, and security) are important values are motivated to pursue these incentivised goals (self-satisfaction) in the context of pay for performance schemes.

GPs’ values form an ordered system of priorities that characterise them as individuals and general practitioners (professionalism) with specialist set of values, behaviours and relationships that underpin the trust the public has in doctors [22] (tradition, benevolence, universalism, tradition). GPs that hold expert positions as generalist medical practitioners are seen as first point of contact for patients in healthcare services (power, security). They offer a doctor patient relationship with mutual understanding of problems that are brought into the practice (tradition, benevolence, universalism).

Doctor as advocate

Professionalism requires that doctors’ advocate on behalf of their patients, all patients and future patients, yet incentivised conformity and indicators conflicted with this aspect. However, this was one concern that should be given the highest priority to advocate on patient safety. Raising concerns about poor care, or the potential for poor care, is a professional duty for all doctors but is not easy; such advocacy needs training, practice, and mentorship [22].

(c) Continuity of care, holism and the caring role of clinicians in primary care

Consequences of cherished values

Holism and continuity of care (benevolence) for example are relevant in the workplace for GPs (universalism). There was a tension between the standardised QOF driven care, being ‘patient-centred’ with clinicians reporting that “it’s not always easy to deal with disregarding, or setting aside a patient’s’ perceived need or to move onto a more pressing practice target (conformity) during personal discussions” [23, 25,26,27,28,29,30].

The trade-off between relevant, competing values guides attitudes and behaviours. When values are shown to be in conflict, not corresponding to the cherished value, then do practitioners attribute more importance to their achievement (completing QOF targets, case finding etc.) or justice (work in best interest of others, benevolence, universalism), and to novelty or tradition (medical model).

Any attitude or behaviour typically has implications for more than one value. For example, A ‘tick box’ approach to medicine encouraged by pay for performance indicators might express and promote EBM and conformity values at the expense of hedonism and stimulation values for GPs. Values influence action when they are relevant in the context (specific) – such as in pay for performance (hence likely to be activated) and important to the GPs (Status, professional progression, and EBM – achievement, power, security) and bureaucrats (focus on GPs performance to the QOF targets-conformity).

Doctor as patient partner

The patient–doctor relationship is at the core of the doctor’s work. The traditional relationship of patient deference to doctors has been replaced by an equal partnership. Values, including integrity, respect, and compassion must underpin the partnership with patients. Integrity involves staying up to date, but also being willing to admit one’s limitations. Doctors can show respect for patients by listening to them actively, involving them in decisions, and respecting their choices (patient centred). Compassion means not just recognising the suffering of the patient, acting to reduce the suffering [22].

(d) Structural & organisational changes

Multiple values

Values guide the selection or evaluation of actions, policies, people, and events in practice organisations. Hence, GPs in self-regulated disciplines (self-direction) decide what is good or bad, justified or illegitimate, worth doing or avoiding, based on possible consequences for their cherished values. But the impact of values in everyday decisions is rarely conscious and activates a multiple set of values. The results show GP values entered awareness when the QOF actions or judgments GPs were considering had antagonistic or conflicting implications for multiple values they also cherished. Such as undertaking templates use (IT) during consultations. GPs are guided by professional practice which is regulated by the guidelines agreed by GPs. They work to a degree, autonomously although subject to audit and some monitoring. QOF impinges by directing activity in a standardised way (conformity, power).

Doctor as innovator

The challenge for doctors is how to innovate amid the innovation happening all around them.

The use of machine (in this context -template) learning was feared could lead to the diluted face-to-face patient doctor consultations with a collaboration in which the machine (template) becomes effectively an independent actor.

It is doctors, rather than machines, who can provide solidarity, understanding, and compassion to patients [22].